Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children, and Families

1762 Pages·2015·225.141 MB·English

by  Susan L. Ward, Shelton M. Hisley, Amy Mitchell Kennedy (editor)

SECOND EDITION
Maternal-Child
Care
~ ursing
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Maternal-Child
Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
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Your guide to...
-
Maternal Child
nursing Care
The Women’s Health Companion
with
Second edition
Look for these icons.

They identify the themes you’ll follow throughout your text.
Holistic care Validating Practice tools of care critical tHinking
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Preview what
you’LL Learn cchhaapptteerr
Caring for the 2200
Developing Child
“It is when we include caring and love in our science,
we discover our caring-healing professions and disciplines
are much more than a detached scientific endeavor,
Learning targets introduce you to the but a life-giving and life-receiving endeavor for humanity.”
—Watson, 2005 p. 3
major concepts and important information ◆
LEARNING TARGETS At the completion of this chapter, the student will be able to:
in each chapter.
◆Describe the principles inherent in the developmental process.
◆Identify and explain the theories of growth and development.
◆Discuss the components for each developmental stage.
◆Address anticipatory guidance for each developmental stage.
◆Develop a developmental care plan for the child and family.
Pico(t) Questions (population • intervention or PICO(T) Questions PICO(T) questions to spark your thinking as you read the
chapter.
issue • comparison of interest • outcome • timeframe) TnAhuner si niinnittgiea ncl ats roteef p teh vianidt EeinBntPce egis-rb ataotse ewsd rt ihpteera bac etPiscItCe a O(vE(aTBi)lP aq)b uilsee steotvi opidnreo tnvhciadete. 1.Dimopeas c(tI )b beehianvgi oraraisl edde vine lao psimngenlet- p(Pa)r einn tt ohdodulseerhs?o ld (O)
emphasize the importance of evidence-based practice effectively guides the research. A PICO(T) question is an 2.Do (P) preschool-age children without siblings who
acronym that stands for population (P), intervention or issue attend group day care (I) develop physical skills (O) at
(I), comparison of interest (C), outcome (O), and timeframe the same rate on average as (C) preschool children with
and how it relates to the content in the chapter. (T). Depending on the question, all or some of the question siblings who do not attend group day care?
components are used in the research process. Use these
Evidence-Based Practice
Bigbee, J. L., Musil, C., & Kenski, D. (2011). The health of caregiving grandmothers: A rural-urban comparison. The Journal of Rural
Health 27, 289–296.
The purpose of this study was to compare the characteristics of Factors impacting these numbers include incarcerated parents,
rural and urban caregiving grandmothers to include physical and mental illness, substance abuse, death, and child abuse or
mental health. The study compares demographic data and differ- neglect. Statistics indicate the following:
ences in physical and mental health between these populations. • One in ten grandparents provide child care for at least
According to national statistics, the past two decades have seen 6 months or more.
an increase in the number of grandparents raising or providing • Two-thirds of grandparents providing care are under the
care for their grandchildren. It is estimated that over 2.4 million age of 60.
grandparents are responsible for grandchildren in their homes.
(continued)
755
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320 unit three The Prenatal Journey
of pregnancy include vascular relaxation from the effects her that limiting fluids in the few hours before bedtime
of progesterone and impaired venous circulation from pres- may be helpful.
sure exerted by the enlarged uterus. Constrictive clothing
also increases the risk for varicose veins. Nursing care for INSOMNIA
patients with varicosities includes regular assessment of
Insomnia may have a variety of causes, including physical
lower extremity peripheral pulses and education. Patients
discomfort, nocturia, caffeine, or stress. The nurse can sug-
should be taught to avoid crossing their legs and the use
gest strategies to enhance relaxation and comfort before
of constrictive clothing such as knee-high stockings. They
bedtime. For example, the woman may incorporate sleep-
should also be encouraged to elevate their legs above the
3665_FM_i-lxx 29/04/15 1:29 PM Page iii inducing nighttime rituals such as taking a warm bath, en-
level of the heart at least twice a day. For some women, a
joying a warm drink such as milk, engaging in a restful
maternity girdle may provide relief (King et al., 2013;
activity like reading, practicing meditation and other forms
Youngkin et al., 2012).
of relaxation, and arranging the bed covers and pillows in
an inviting way that promotes rest.
DYSPAREUNIA
Dyspareunia, or painful intercourse, may result from
ROUND LIGAMENT PAIN
pelvic congestion and impaired circulation caused by the
enlarging uterus. Also, as the pregnancy advances, finding The round ligaments support the uterus as it enlarges dur-
a position of comfort for intercourse may become increas- ing pregnancy. These structures attach to the fundus on
ingly difficult because of the enlarging abdomen. Conc3e6rn65s_Ch1e0a_c2h9 3s-i3d3e4, p0a8s/1s 2t/h1r4o u10g:h2 8t hAeM i n Pgaugien 3a0l 5canal, and insert into
that intercourse will harm the fetus may also interfere with the upper portion of the labia majora. As the uterus en-
Pserxuale enjPoymaentr ande inc refaseo the rlike lihtoohd of deysp arreu-ealargLes, thwe rouond ligramLentds stre tch and produce a painful
nia. Unless a medical condition contraindicates inter- sensation in the lower quadrants. Once pathological con-
course, the patient and her partner should be reassured that ditions such as preterm labor, rupture of an ovarian cyst,
ointefrco unrse isu safer dursingi pnregngancy . EPdurcatiaon abcoutt sexi-ceecto.pi c p r e g n a n c y , a p p e n d i c i t i s , g a l l b l a d d e r d i s e a s e , a n d chapter 10 Promoting a Healthy Pregnancy 305
ual intimacy should include suggestions for comfortable peptic ulcer disease have been ruled out, the nurse can ed-
positions for intercourse and alternative methods for mu- ucate trheeq upairteiemnet nabtso uart et hine ccraeuassee odf itnh ep rpeaginn aanntd a mdoaklees scuegn-ts (ages IRON AND VITAMIN C. As blood volume increases during
tual sexual satisfaction (King et al., 2013; McDaniel, 2010). gestion1s3 ftoor 1re8l)ie, fw mheoa snuereeds. aTna kinintagk ae w oaf r1m,3 b0a0t hm, agp/dpalyyi.n Wg ithout pregnancy, the number of circulating red blood cells also
heat, ssuuppppolretimnge nthtaet uiotenr,u ms wositth w ao pmilelonw f awilh teon c roenstsinugm, ea naddequate increases. Maternal iron intake must be increased to main-
“ ” using aa mproeugnnatsn coyf g idrideltea mrya yc haleclpiu tmo .d iCmainlciisuhm th ei sd iescssoemn-tial for tain the oxygen-carrying capacity of the blood and to pro-
What to say —When asked about sexual fort (Kminagin etta ainl.,i n2g0 1b3o Ynoe uanngdk itno oett ha l.m, 2in0e1r2a)l.ization and calcifi- vide an adequate number of red blood cells. Fetal iron
activity during pregnancy
cation. During pregnancy, calcium must be available to needs are increased during the last trimester. At this time,
Couples have many questions regarding sexual activity HYPEtRhVe fEeNtuTsI LfoArT thIOe Ngr oAwNthD a SnHd OdeRvTelNoEpmSSe nOt Fof the skeleton iron is stored in the immature liver for use during the first
during pregnancy. These questions relate to the safety of BREAaTnHd teeth. 4 months of life while the liver matures and liver enzymes
sexual intercourse, potential complications, when to stop IncreaDseadir my petr“aoWbdoulhiccat sta, c tetoisvp iSetyca iydalu”ly rdi nmegvi elpklro eapgnsnd ya nmocuiylrk ic npocrmroemdausuecnstsic, actoionn- are being produced. The newborn uses the stored iron to
having intercourse, and sexual positions that facilitate the amsotiutuntt eo fts hckaeirl lbbso etnsht rd oniouuxgtirhdi etei oxinan mathlp es lmoesua ratcenredns a hol efrl epcsfapulicrl aihutoimnryt.s .Three compensate for insufficient amounts of iron in the breast
comfort. It is important for the health-care provider to systemd.a Hilyyp seervrvenintiglsa tioofn d daeicryre apsreosd tuhcet sa maoreu nrte coof mcamrbeonnded for milk and in non-iron-fortified infant formula.
address sexual activity early in the pregnancy in an dioxidwe oamnde nm; aoyn ter igtog etrw ao f eaedldinitgi oonf a“la idra hiluyn sgeerrv.”i nPgast ioenf tmsilk are The iron RDA for prepregnant women ages 14 to 18 is
honest, open manner and to encourage the couple to may alrseoc oexmpmereienndceed s hdourrtinnegs sp oref gbnreaantchy r (eNlaatetdio tnoa ul tIenrsintietutes of 15 mg/day, for women age 19 and older, 18 mg/day, and
communicate with each other. The nurse can address the enlargHemeaelntht a[nNdI Hth]e, 2u0p1w1aar)d. pOrtehsesur rrei cehx esrotuedrc oesn otfh ec adlci-ium in- for pregnant women, this amount increases to 27 mg/day,
couple’s concerns with the following statements: aphragcmlu.d Oe nlceeg upmatheso,l odgaircka lg croenedni tlieoanfsy svuecghe taasb ulpesp,e dr rrieesd- fruits, starting by 12 weeks of gestation (Institute of Medicine,
piratorayn din nfeucttsio.n, asthma, cardiac problems, and anemia 2001). Iron can be found in a variety of food sources. Many
“It is perfectly safe to continue sexual activity through- have been ruled out, the nurse should explain the cause of individuals may not be aware that adequate amounts of
oiduetn ytiofiuers prirsekg nfaacntocyrs u tnhlaets ms ayyo uprr edcoluctdoer yooru nr uacrstiev imtyi d(we.igf.e, hscyipoeursvlye natt itObleaomptnitoepi nmtm tteoioza ri lnet shggueup Olppaluateettmi cheeonenrmtt bsaernesda— tshuTingeaggce. hsOtin ttghh eparat mtsieheneat sscu otrone s-avoid ilreonnti alsr,e fsopuinnadc ihn, fokritdifineedy rebaedayn-st,o -leiamt ac erbeeaalsn,s w, hsiotey bbeeaannss,,
a orispkt ifmor ipzrinetger mo ulatbcoorm). eWsi tshh onwo ryisoku f hacotwor st,o s exual ac- that may be helpful include breathing into a paper bag to shrimp, and prune juice. Red meats, including beef, duck,
tievsittya bisl issahfe t hfoer cyoouur asned o yf oaucrt iboanb yth aast l oacnhg iaesv yeso uth ceo ntinue decreaseB tohnee smymeapl,t soommse toifm heys puesrevde nast iala ctaiolcniu, mm asionutracine,i nshgould be and lamb, contain moderate amounts of iron as well. Some
tob persat cptiocses sibaflee soeuxt bceohmaveiso fros ra sy oyouur pwaotuieldn ti.f you were not good poasvtouirdee, da ndudr isntrge ptcrheginnga ntchye. Tahrmis ss uapbpolveem tehnet ihs efardequently of the best food sources for iron include oysters, organ
pregnant. As you gain pregnancy weight, some sexual po- (King et caoln.,t 2am01in3a; tYeodu wnigthk ilne aedt, aal .t,o 2x0in1 2th).at readily crosses the pla- meats (e.g., liver and giblets), and fortified instant cooked
3665_Ch10_293-334 08/12/14 10:28 AM Page 294
sitions may be less comfortable; for comfort, you can try centa and can result in high levels in the fetus. cereals. Interestingly, canned, drained clams provide the
woman on top and side-lying positions. A sexual activity NUMBNESS AND TINGLING IN THE FINGERS highest amount of iron per serving, with 23.8 mg of iron
29t4o a v o i d u nditu trhirneeg Tpher Peregnantaal Jnoucrnyey includes oral sex during which NumbnesVsi taanmdi nti nDg,l ian gfa ti-ns othlueb filen gveitrasm mina yo bbtea iansesdoc liaartgeedly from in each 3-ounce serving (NIH, 2012).
water or air is placed in the vagina.” While most other necessary nutrients can be met
with hcyopnesruvmenintigla ftoiortnifi oerd fmroilmk onre jruviec ec,o fimshp roeislssi,o ann din d itehteary sup-
through a balanced diet, it is almost impossible to meet the
Evidence-Based Practice mediapnl eamnde nutlsn, aisr inmerpvoerst ainnt tihne t harem ab. sPorrepgtnioann cayn dis monetea booflism of
NOCTURIA maternal daily requirements for iron without a dietary sup-
O’Connor, P. J., Poudevigne, M. S., Cress, M. E., Motl, R. W., & Clapp, J. F. (2011). Safety and efficacy of supervised sttrehngeth mtrainoicngsatl cfriueqmu.e Dntu prihnygs iporleoggnicaanlc cyo annddit iloacntsa atisosno,c itahtee dR DwAith for vita-
adopted in pregnancy. Journal of Physical Activity and Health 8, 309–320. plement. Consideration must be given, however, to the gas-
Nocturia, or excessive nighttime urination, is more com- carpal mtuinnn Del issy 6n0d0ro ImUe ( (1c5o mmpcrge)s/sdiaoyn. oSfe tvheer em medaitaenrn naelr vviet,amin D
Previous studies have found that physical inactivity predisposes training at a low to moderate velocity with scheduled rest periods trointestinal side effects of supplemental iron, which
tmo reodunce d dfitunerssi anndg i nctrehaseed fefitarl asntd maatnerdna l ritshks idrurdin gtribmetweesent eexrersci.s esW. Parhticeipannt s twheree instructewd tho reatree ed xeiertci fistec raievneclsy dhoaws nb eteon t haess torcainastevder wsei tcha rbpiaolc hliegmamiceanl te).vidence
include constipation, black tarry stools, nausea, and ab-
pwregonmancay. nMa taersnasl ufitnmesse asn d ase vrerealc auspemctsb ofe fentatl apndo msa-itioinnte,n stithy uesi ngg ar aravtedi dpe rcueitveedr euxesrtion (RPEM) scaalei. nA traaotinifgn odifnisgo grdoeorde dp osskteulreet,a el lhevoamtienogs ttahsei sh, acnodnsg oenn iata pl irlilcokwets, and
ternal health have previously been found to improve through the 13 represented moderate intensity, 11 represented fairly light, and dominal cramping. These side effects may exacerbate other
unseo o fl loown- tgo emrod ceraotem-intpenrsietys esxeercsis et dhurein gp perelgvnainccy .v Theesserlastin,g as onf 1d0 obr lleosso redpr eflsenotewd l otwo intensity. wExthernialle lo asfdrl eawaecsptuinregs, oinr twheea nrienogn aa twe.r iWst hbirlaec teh werhe eins isnlesuepffiincgie mnta eyvidence
pregnancy-related gastrointestinal discomforts. Daily iron
ptuhrpeo ske oifd thnis estyudsy wisas eton dhescarinbec theed pr.o gTrehssiiosn offa scupteor-r, cporomgresbsivienlye indcre waseidt bhas ead non iRnPE- responseps tro oeavchi edxfeeorc risse .tyhme prteocmomatmice rnedliaetfi.o nA ftohre srcmreoesnkiinng c aalrlp parle tgunnannet lwomen
vised, low- to moderate-intensity strength training program im- Participants usually performed the abdominal exercise from a supplementation is often initiated at around 12 weeks of
pclermeeansteed dam gonlgo ma seamrpulel aofr p fireglntarnat twioomnen r. aA tfeur,t hienrcrestaansdeinsg ptohsiteio nn aende dwe rteo a sukerd it-o draw ing tlhoeirv aebd fowomiirnta hlv ithaemati nt hDe rdaepfiyc aienndc ys,u iptp ios ritm tpoo hrtealnpt rteol ieedveu cpaatien women
gestation to avoid compounding the nausea commonly
pnuarptosee. w aAs tlot ehxpoloure gthhe in ctidhenecre eof aissso cniatoed rmeusmculoesdkelye- form unscolesc atsu if rtriyaing, ttoh reeac hn thue rspsinee. Repetitaionnsd w erien haeflblda oamtu tm thaeti onnee adn fdo r pvrietavmenint Dw–rifsotr tmifioevde fmooednst so ri ss uaplspolements
tocacalc iunnrjrue rntiecese,a olucf mphbroa btr lheemnedaut irpca nsacyemt,i pbetloonmodst, p(aere.bgs.s,ou srwue ectlhl iantnghg ienes ,h acannadd ust hosere o8ifn gthn, rtoohuegc hbtolouuot drth ipear etr saasiunnrinedsg .w Faievrede mmvineiuastseeusr eadft,e ar ncdo mappvalretaitciniipgla atnhbte(s tlAwreaeiCn re(-OOG’D,o 2n0n1e1lla,; EHliaor,r i&s, D20a1y1, )2.0 F1o0r)t.i fied milk and ready-to- prevalent during the first trimester. Adequate water intake
helps to decrease constipation, and patients may take the
feet; headache or visual disturbance; chest, pelvic, or abdominal asked about potential problematic symptoms and back paeina. t cereals constitute the major food sources of vitamin D,
pain; irregular heartbeats or dizziness; and unexpected vaginal The researchers stated that no musculoskeletal injuries were iron at bedtime if abdominal discomfort is experienced
bleeding or leaking). reported for women at risk for low back pain. No chest palpiwtatihonisch is also proedvuicdeedn ince th-Be asksiend b yP rthaec taicctieo nB oofx suensl iagnhtd.
when taking iron between meals. A systematic review pub-
The sample was composed of 32 healthy pregnant women who or chest pains were reported. Symptoms were reported 13W timoesmen who do not include milk in their diets should be
were primarily recruited through midwives and obstetricians. The and included dizziness (8/13) and abdominal/pelvic pain (4/13). Questions highlight current research lished by the Cochrane Collaboration (Pena-Rosas, De-
participants were between 21 and 25 weeks of gestation and their One person reported a headache. Most symptoms were retpaorutedght about other vitamin D sources such as cereals, egg
ages ranged from 18 to 38 years of age. They were at low risk for within the first 3 weeks of the study. The percentage of incryeaosel ikns, liver, and faanttdy fienshc osuucrha gaes syaolmu oton , tshairndkin aesb,o auntd htroowut . Regil, Dowswell, & Viteri, 2012) shows that taking iron
any pregnancy-related complications and free from back pain or a the external load across the 12 weeks was found to be statistically supplements one to three times per week is just as effective
history of back pain. Women who reported use of regular strength significant and reported as follows: leg presses (36%), leSgu cunrlscreens withy ao ure ccaonm minecnodrpedo rSaPtFe ervatiidnegn ocfe -8b aapsepdea r to
at preventing anemia as taking them every day, and the in-
training and those who reported uncontrolled psychiatric conditions (39%), lat pull down (39%), lumbar extension (41%), and blegl oexc-k vitamin Df–inprdoidnugcsi ningt oU Vyo ruary sp. rIanc tpircaec.tice, however,
and orthopedic or cardiovascular limitations were excluded. tensions (56%). The researchers reported that exercises were per- termittent dosing schedule is associated with fewer side
Prior to initiating the exercise program, experienced trainers formed at a low to moderate perceived intensity with a meamn RoPEst people do not apply adequate amounts, cover all sun-
effects.
taught and supervised participants on the use of strength training of 10.5 to 12.9, which did not change significantly throughoeuxt tpheosed skin, or reapply sunscreen regularly. Most likely, the
and specific types of exercises. The participants were then expected 12-week period. A 14% increase in lumbar endurance was reported.
to implement strength training twice a week for a 12-week period. No significant changes in blood pressure were reported durisngk ainnd synthesizes some vitamin D even when it is protected by
Data recorded included blood pressure, extension endurance ex- at the conclusion of the 12-week training. The researchers conscluudnedscreen as typically applied (NIH, 2011b).
ercise test, and report of symptoms or musculoskeletal injuries. that use of supervised, low- to moderate-intensity strength training Nursing Insight—When teaching about iron
Participants were instructed to complete a warm-up that included during pregnancy is safe and efficacious.
supplements
5 minutes of walking on a treadmill. Following the warm-up, par-
ticipants performed six resistance exercises: dual leg extension, 1. “How is this information useful to clinical nursing practice?” Cultural Diversity— Maternal Vitamin D
dual leg press, dual arm lat pull, dual leg curl, lumbar extensions, 2. “Based on these findings, what are implications for further Deficiency Nurses can teach patients about substances known to decrease
and a transverse abdominis muscle (abdominal) exercise. Using research?”
the Universal Gym and Cybex Eagle for the first five exercises, the See Suggested Responses for Evidence-Based Practice on the absorption of iron. Women should be taught to avoid con-
number of sets and repetitions were constant throughout the DavisPlus. African Americans and other women with naturally dark skin suming bran, tea, coffee, milk, oxylates (found in Swiss chard
whose melanin affects UV penetration are at the greatest risk and spinach), and egg yolk at the same time as they take the
for vitamin D deficiency. Women who habitually cover most iron supplement. Also, iron is best absorbed when taken be-
Introduction achieve an optimal pregnancy outcome. Health-ocafr etheir skin with clothing for religious or cultural purposes, tween meals with a beverage other than tea, coffee, or milk.
providers must provide guidelines for safe and benefivceiagletarians, and those who live in northern latitudes with lim-
This chapter focuses on health promotion of childbearing exercise, which include teaching pregnant women about
women during preconception and throughout pregnancy. theT ehffiesc ctsh aopf teexre arclsiose d ainscdu wssoersk .the effects of medicatiitoends exposure to sunlight are also more likely to be deficient in Vitamin C (ascorbic acid), important in tissue forma-
care and provides information and education to women during pregnancy and provides information concervniintgamin D. Because newborn vitamin D levels are largely de- tion, also enhances the absorption of iron. Women who
and families, which enables them to plan for their preg- safe versus unsafe medications. Included in this sectiopne insdent on maternal vitamin D status, infants of mothers with
nancy and to develop a healthy body and a healthy mind information about over-the-counter medications, herbal take iron supplements should consume foods or beverages
surrounding the pregnancy. therapies, and prescription medications. Certain medoicra -at high risk of vitamin D deficiency are also at risk for vita- that contain vitamin C. Food sources rich in vitamin C in-
Another important facet of health promotion during tions are considered to be safe for use during pregnamncyin, D deficiency (ACOG, 2011a).
pregnancy concerns adequate nutrition and weight gain. and these are incorporated into the discussion about the clude red and green sweet peppers, oranges, kiwi fruit,
Women need to have an understanding of essential ele- common discomforts of pregnancy.
ments required for a healthy pregnancy and of how to in- Nurses and other health-care providers can teach patients
corporate them into their daily diets. Along with diet and about common pregnancy discomforts to help alleviate anxi-
nutrition, exercise, work, and rest must be balanced to ety and fear. Prenatal education also promotes empowerment
3665_Ch20_753-785 31/12/14 2:41 PM Page 783
chapter 20 Caring for the Developing Child 783
Summary Points
3665_Ch21_786-839 14/01/15 2:B14o xPM 2 0 P-a1g0e 8A0n0ticipatory Guidance for Adolescents
◆ Prominent theories of development allow the nurse and
Nutrition:Provide 3 healthy meals and 2 to 3 healthy snacks per day; avoid
family to have a deeper understanding of the “why’”
high-fat, processed, and “fast” foods; manage weight through exercise and
behind developmental tasks and stages.
healthy nutrition
3665_FM_i-lx8x0 0 2 9 / 0 4 / 1 5 1 : 2u9n PiHtMe as l itPxha PgroCema irvointigo nfo:rIm thmeu nCizhailtdio nasn (dse Fea immmilyunization schedules at http:// ◆ Each child possesses his own way of learning about the
www.cdc.gov/vaccines/schedules/); oral health; discuss sex, sexual feelings, world around him.
protection against sexually transmitted infections; abstinence as the best
auscultation, warwmaiyn tgo tphreev ednita pprhegrnaagnmcy oanf dt hseex ustaelltyh troasncsmopittee db einffoecrteions; if Chaavrindg isaexc, Asses◆smInefnotrmation about growth and development, newborn
auscultation, placdiinscgu stsh beir tsht ecothntoroslc aonpde s aofen s ethx epr acchtiicleds’;s d biscaurses ssmkionk,ing andT shubes tacnhceest is inspthercoteudg hfo ard soylmesmceentcrey, ains dim ppuolsratatinotn fso, ra nthde nurse and
and comparing bialbautseer aavl obidraenacteh; ssyomupntodmss. of stress and how to deal with it all peripheral pulfsaems ialrye. palpated (Table 21-6). In slim chil-
Focus on Safety:Seat belts; driving safety; sports and wadterre nsa,f eptyu; lsatio◆ns Pfrroinmci pthlees hoefa rgtr omwatyh baen vdi sdibevlee.l oTphme ennut rcsaen assist the
sunscreen; avoid tanning salons
Sleep-Wake Patterns:Require 8 to 10 hours of sleep per nigbhte gins palpation nwuirthse t wheh cenar toetaidch pinugls eth, em faakminilgy nabooteu ot ft haeniyr child.
focus oPhnysi casl aDefveelotpyment:Explain development of secondary sdeixs ctheanradc-ed nec◆k vIet iinss i,m apnodr ctaonntt fionru tehse w niuthrs teh teo brreaccohginailz aen cdultural influ-
teristics; females: explain menstruation and masturbation; malreas:d eixapll apinulses. Caepnilcleasr yo nre gfirlol wist has asnesds eddev aesl owpemlle anst .changes
Important remsapsitruarbtoatriyo ns iagnnda nloscturnal emissions in the fingern◆ailEs v(een.g .t,h coluugbhb ianlgl cohf itldhree nfi nggreorws) ains dn odteevde.lop in their
The nurse must reCcooggnniitziev eth aant dn oErmmaolt iborneaatlh D seovuenldosp amree netq:uParla bisie- academPice sruicpcheses;ral edemoa wann dm caynanneors, ies aacrhe cahsisleds steydp idcaulrlyin fgo lploawlpsa -a designated
monitor for academic struggles; encourage new challenges; model respect
laterally in intensfiotyr ,d rihffyetrhinmg ,o apnindio pnist cahn.d T nheee fdosl loofw oitnhger sre; smpoirdaetlo croyn flict resoluttiioonn s torafte t-he femorpaal,t tperonp loitre tarla,j epcotsotreyr.ior tibial, and dorsalis
signals may indicgaitees ; tehxapte cat rinecsrpeiarasitnogr yin cdoenpednitdioennc eca fruosmin fga mdiislyt;r peesse ri sgroups anpde adctiisvi tpieuslses. ◆ Identifying the specific characteristics that define the
present in a childw:ith peers are increasingly important; provide for some privacy atC hoomnet;inued pFalopcatuiosn o onf t hSea cfheetsyt chanig ihdleingthiftys tihme pporerst-ant
temperament of a child can help the nurse and family
• Noisy breathindge voerl ospnmoreinntg o (fa iinrt ipmaastsein rgel athtioronushgihp sa; tneaacrrho two ebda luapnc-e school,e wnocrek, oanfd thrills, pwurhnoidcteherc sattriaven ead mcthoeena susenuqiurqeuesne ncteeo s osk fo ebfe ltpoho emd c hofliotlhdw.einrsg and
per airway) mapye einr dgricoautpe p naartsicailp patoiolynp; sb, efgoirne ipglann bnoindgy f oorb tshteru fcuttiuorne, rapidly from high pressure to low pressure. The rough vi-
choanal obstruMctoiotonr, hDyepveertlrooppmhieendt a:dDeaniloyi dre tgisuslaure ,e oxer rocibsee;s istuy.pport partibcirpaattiionng in s ensat◆iocnFhsai almdreirl iefeensl t mo buyut sp to laafcd hijnuagsr tmt htoe’s pnwaelawmy .s okfi ltlhs ea hnadn tdasks at each
• Grunting is caoursgeadn ibzye dt hsepo grtlosttis closing at the end of expiration over the chest. Sstoamgee ovf ednetvreiclouplamre snetp.tal defects result in
Discipline:Increase levels of responsibility at home to foster movement
and may suggest respiratory distress or pneumonia. thrills at the lo◆wUern ldeeftr ssttaenrdnianlg b gorrodwert.h P aunldm odnevaerlyo sptmeneonst isprovides the
to adulthood; restriction of privileges
• Nasal flaring (intermittent outward movement of the nostrils) may cause a thrilnl uarts teh we iuthp ptoeor llse tfot sdteevrnelaolp b ao rpdlaenr, owf hcaerree afsor the family
happens on inspiration and is a form of accessory muscle use aortic stenosis isa cfrroesqsu ceanrtel yse pttainlpgasb.le in the suprasternal
found in a variety of conditions such as respiratory distress syn- notch. ◆ Anticipatory guidance is an important aspect of the
drome (Venes, a2s0k1e3d). how things are at home, Senglui states that her parents teaching provided to parents by nurses.
• Coughing (a foarcreef u“lc eoxnpsitraatnotrlyy ecfrfiotircti)z iisn ag ”n ohremr aal npdro pceustst itnhga ta lot of pressurNe uonrsing Insight—Point of maximal impulse
clears the throahte bru atb coaun ti nhdeirc agtrea adne sin. fTehcteiyo na,r aes cthomnsai,d leurnign g making her give up
(PMI) Review Questions
disease, or sinusscithiso.ol sports.
• Stridor (a highc-rpiitticchaeld ,t hhainrskhi nsogu nqdu eocsctuiorrninsg during inspira- The point of Mmuaxltiimpalel iCmhpouilcsee (PMI), or area of most intense
tion) results from air moving through a narrowed trachea and
pulsation, and the point of apical impulse, or the impulse corre-
larynx and can 1in. d Bicaastee dc roonu pw (hVaetn Sees,n 2g0lu1i3 h).as said, what are you most concerned 1. The pediatric nurse assesses the toddler’s fine motor
sponding to the apex of the heart, are usually located in the same
• Wheezing (a musicaabl onuotis?e ) results from air moving through mu- area of the chest. sGkeilnles rbalyly o, bthsee ravpiincgal wimhpicuhls tea issk f?ound just lat-
cus or fluids in 2a. n Warrhoawte add ldoiwtioern aailr wquaey stthioant sis wasosuolcdia ytoedu wasitkh Senglui? eral of the left m iAd.claBvuicttuolanri nlign ea (sMhiCrtL) and fourth intercostal
asthma. B. Writing with a pencil
3. What nursing interventions are appropriate at this timspea?ce (ICS) in c h Cild.reHno yloduinngg ear sthpaono 7n yteoa resa.t For children older
• Hoarseness is a rough quality in the child’s voice and can mean than 7 years, it is found in the fifth ICS. The stethoscope is placed
D. Using the pincer grasp
that the airway is iSneflea mSuedg.gested Answers to Case Studies in the text oovne rt htehis area for auscultation of the apical pulse.
◆
• Crackles is a fine, hEilgehc-tproitnchice dS tsuoduyn dG uheidaerd o or nD ianvsipspiralutiso.n or ex- 2. According to Piaget, an infant uses his or her senses
piration produced by air passing over retained airway secretions to learn and explore the environment. Which action
or the sudden opening of collapsed airways found in several res- Auscultation bies gtihnes mwoitsht atphper dopiarpiahtrea fgomr tohfe tnhuer ssete ttoh oim- plement to
piratory conditions (Venes, 2013). scope, and furthedre etevramluiantei oonb joecf tt hpeer hmeaanret nscoeu?n ds is done
• Rhonchi are a low-Npiutcrhseindg w Dheiaezginngo,s sensoriTnhge, oDre svqeuloeapkiningg Child with the bell o f t hAe. sPtleatyhionsgc tohpee g (aFmige. o 2f 1p-e7e)k. -Ta-ob oaossess for
sound indicating a partial airway obstruction. Mucus or other the first heart s o u Bn.dE (nSco—utrhagei n“lgu tbh”e sionufanndt) t,o t hshea nkue ras er abttel-e
secretions in th1.eG ariorwwtahy ,a bnrdo Dnecvheialolp hmyepnetr,r aelatecrteivdi trye, laotre tdu tmo oinras dtehqautate caregtainkisn ga,t the four t h Cor. fiPfuths1h leinftgI Ca Sb uattt tohne o Mn CanL .o Tvhereh fierasdt hmeoabrtile
occlude respira2t.oeInrnyjuv iprryoa, nshsmiagehgn ertisas lkc o afron sr tcrimealuaustlaeedt ia otinorw dlaaecfiyk c ooiebfn sactwireuasc.retinoenss of environmesnotaulnd reflects t h eD c.loPsluarcein ogf tthhee cmhiitlrda iln a na ds ttrroiclluesrp aindd v gaolvinesg for a walk
(Venes, 2013). hazards. and signifies t3h.e Tbheeg ipnendiinatgr ioc fn vuernset riisc purloamr cootinntgr aacnttiiocinp aotrory guidance
• Color changes3 i.nS ethlfe-e sstkeienm (e, .cgh.r,o pnaicl lloorw, m reolatttleind gto, ainnedf fceycatinveo sreisla) taiorenship wsityh sptaorelnet.s The seconadb ohueta rsta fseotuy ntdo (tShe— mthoteh “edr uobf” as o1u0n-md)o rnet-h-old infant.
2
significant respiroart opreye rssi.g nals and usually indicate cardiac in- flects the closureW ofh itchhe sptuatlemmoennatr yis annodt aaoprptirco pvrailavtee sf oanr dthe nurse to
volvement. signifies the begininnicnlugd oef iant rtihael cteoancthraincgti osens soiro dni?a stole. The
• Chest pain is causNedo wby Caaltenr aYtoioun— inD cehsecsrti bster uncoturmreas,l ngoronwputlh- and nurse hears “lu nb cAdu.Lbe“.D”Xo- Sntoyt lleea vree svmiaelwl o bQjeuctes sotni othnes fl aoto rt hbee ceanudse

• Cmlounbabryin ingv(oelxv1ceem. s esEinvdteu, ocgarr otaew vftahar mioefit lyite hosef asrdbeoesofvptu eitrtilas owstpouhmreyase t can ottton ?t dheietxi poeenncsd.ts doufring growspthl Diatn usdroiunng di nbs ep co i ar f au Bets.iaeoc“y ntKohh,u e etcerh phpbe aau tSbhplm2yet eswosorinid ulhaeln r ebdrylea p ivmcl sarya aluvoywpe ulb i tcneiolgd o a pessuroendesotvi nibesf.lnly”ietg yhayosot luuyarr baarbeya sfr oomf
the fingers or toesd)e ivs eulosupamllye nats saotc ieaatcehd wdeitvhe clohpromneicn htaypl sotxaiage? later than the asotrretincf gavtlahlilnv/weg. oeTuahtk ionsf e ptshhsey ascinroidblo. ”gpirceapl aspreli tytionug ifsor course
and pulmonar2y .d iEsedauscea.te families regarding anticipatory guidance aht eeaacrhd as a “lub t- e d sCutb.s” “a Pannuddt nissaa wfteiitotyhn ianlol tclhkicese cnoosnnu teraxelt l e oxcf aanmboinrimnetaast l.ioton .prevent
accidents.”
developmental sta3g6e6?5_Ch20_753-785 31/12/14 2:41 PIMf sPpagliet t7i6n1g is also heard during expiration, this is suggestive
D. “Allow your baby to stay alone for short periods of
3. Describe effective discipline for each age group? of pulmonary valve pathology.
time to promote independence.”
Two other heart sounds may be heard during the cardiac
cycle. The S and S heart sounds are both heard in diastole.
Critical Nursing Action—Adventitious L u n g 3 4 chapter 20 Caring for the Developing Child 761
A physiological S is heard frequently in children and
Sounds 3
young adults. It is heard best at the apex in a left lateral
Nursingly iCnag rpeo sPitlioann bDye llaisyteedn iGnrgo wfothr tahned sDoeuvneldo pinm eenatrly diastole
nurAs i3n-ygea rc-oald rcehi ldP ilsa bnrosug phtr oinvtoi dthee ctlhineic with a chief complaint
right after the S . It is called a ventricular gallop and, be-
of recent coughing. The mother states that the child has noN fuervseirn ogr Diagnosis:Delayed grow2th and development, related to chronic illness
in-depth information you need cause of the cadence of the rhythm, sounds like the word
cold symptoms, but began coughing several days ago. The nMuersaes uaruasb-le Short-term Outcome:Child will maintain current weight and participate in age-appropriate
to plcaulnta taens adll cluanrge f iefoldrs apnadt hieeanrst sw hweeitzhin g and localized rhaocnticvhiti ioesn, as pos“siKbleen.tucky.” Although an S3 is most likely a finding not as-
comtmhe olenftl ysid ee nbcuto nuonrmtaelr veedsic nuloarr smouanld s on the right side. MTheea nsuurrsaeble Lonsgo-cteiarmte dO uwtciotmh eh:eCahritld d wisilel aresaec,h t ahgee- afipnpdroipnrgia tseh gorouwldth baned d doecveul-opmental milestones.
must notify the health-care provider immediately for furtheNr OevCa lOuuat-comes:m ented and reported. S4, heard in laNtIeC dInitaesrtvoelnet,i oisn sh: eard
and tpioan tahnod ltoregatimcaenl tc.onditions. Growth (0110o)n Nlyo rimn acl hinilcdreraesne iwn hboon he asivzee acnodngenital heNarutt rditiisoena Msea nsaugcehm eanst (1100)
body weigphtu dlmurionng agrryo whtyhp yeeratres nsion and pulmonic sDteevneolospism. eInt tiasl Ennehvaenrcement: Child (8274)
Child Development: Middle Childhood (0108) Normalization Promotion (7200)
Milestones of physical, cognitive, and psychoso- Activity Therapy (4310)
nursing diagnoses, based on cial progression from 6 through 11 years of age
the information you obtain during (specify other age groups as appropriate)
Play Participation (0116) Use of activities by a child
your nursing assessment, form from 1 year through 11 years of age to promote
enjoyment, entertainment, and development
the basis for your selection of the
nursing interventions that will Nursing Interventions:
1.Build a trusting, supportive relationship with child and caregivers by taking time, actively listening to concerns,
address the problem.
aconndc eorfnfesr, ianngd ionfffoerrimnga itniofonr manadti oenn acnodu reangceomureanget.ment.
RATIONALE:A trusting relationship facilitates implementation of developmental interventions.
2.Monitor child’s height and weight (specify frequency) and record on a continuous flow sheet.
RATIONALE:A flow sheet provides a continuous record of the child’s growth over time.
3.Monitor attainment of age-appropriate developmental milestones.
RATIONALE:Provides information about the child’s developmental needs.
4.Collaborate with child, caregivers, and dietician as needed to provide healthy high-calorie and high-protein
meals, snacks, and drinks that the child enjoys.
RATIONALE:Collaboration ensures that the diet will be appealing to the child and provide the necessary nutrients
for growth and development.
5.Encourage caregivers to view the child as “a child with an illness” rather than “an ill child.”
RATIONALE:Encouraging normalcy within the bounds of what is physically possible assists the child to reach
maximal growth and development.
6.Assist caregivers to identify the child’s special needs and make environmental adaptations to promote normalcy.
Refer to community resources as needed (specify).
RATIONALE:A supportive, adaptive environment may downplay the child’s disabilities and enhance normal
development.
7.Refer caregivers to appropriate support groups (specify).
RATIONALE:The support of other families and children may provide additional information and ideas to foster
growth and development.
8.Encourage caregivers to hold the same expectations and use the same parenting techniques for the child as
they would for other children in the family, as appropriate.
RATIONALE:Consistent caregiver expectations and parenting techniques help the child view himself or herself
as a normal child.
9.Provide anticipatory guidance to caregivers about age-appropriate developmental tasks and milestones for
the child.
RATIONALE:This provides information for goal-setting in development enhancement.
10. Encourage caregivers to provide age-appropriate activities and normal childhood experiences for the child
whenever possible (e.g., school, scouting, and camp).
RATIONALE: Participation in usual activities and experiences for age facilitates the child’s physical, emotional,
and social development.
11. Assist the caregivers to provide for and encourage the child’s interaction with other children.
RATIONALE:Interaction with peers promotes the child’s social development.
12. Collaborate with care provider to enlist the assistance of a Child Development Specialist when the child is
hospitalized.
RATIONALE:This provides professional developmental support specifically for the hospitalized child.
Continued
3665_Ch21_786-839 14/01/15 2:15 PM Page 829
chapter 21 Caring for the Child in the Hospital, the Community, and Across Care Settings 829
feeding/eating schedule (see Procedure 21-1: Inserting feedings are preferred over total parenteral nutrition because
3665_FM_i-lxx 29/04/15 1:29 PM Page v an Oro- or Nasogastric Tube at the end of this chapter). they preserve the stomach’s mucosa, allow the digestive
process to continue, and are cost-effective.
OROGASTRIC AND NASOGASTRIC FEEDING TUBES. For newborn
infants requiring gavage feedings (a feeding done using a
3665_Ch10_293-334 08/12/14 10:29 AM Page 334 tube that is passed through the nares and into the stomach; Nursing Insight—Psychosocial needs of the
the food is in liquid form, usually at room temperature), the infant receiving gavage feedings
orogastric route is preferred because newborns are obligate
334 unit three The Prenatal Journey
nose breathers. The tube is inserted and then removed at The time taken to administer a gavage feeding can be used in
3665_Ch10_293-334 08/12/14 10:28 AM Page 305 CONCEPT MAP the end of the bolus feed. If the tube is to be left in place, the the same way as in a regular feeding. Place the infant comfort-
Promoting a nasogastric route should be considered. Nasogastric tube ably in the mother’s arms with the head elevated. Provide the
Healthy Pregnancy
Preconception Counseling Nutrition Medications Activity
H e a lcthyh Boadyp: astseess r 10 PFarcotomrs Aoffetcitningg: a Healthy P• Ernecogurnagae cnoncsuyltation Work: as3se0ss5 impact Procedure 21-1 Inserting an Oro- or Nasogastric Tube
• Medical/menstrual • Eating disorders: pica, with PCP to determine • What is the nature of the
history anorexia/bulimia drug safety work?
• Findings from • Cultural influences/ • Know teratogens and FDA • Is there exposure to toxins?
physical/lab exams religious beliefs classifications for meds • What is the number of
r1e3q tuoi r1e8m)e, nwths oa rnee iendc raena siendta ikne p orfe g1n,3a0n0t amdgo/ldeascye. nWtsi t(haoguest pr••• eESLPIiaxTfgeRptIisseo/tnnscyOuthl/erfial aedNcm hhtonooil yoicA dgec esilNnlyneet,sDics tVhIeTA nMuI•N•• mNuBOAresbs sitinaenbCgisgn sv: .e nefougrrtar Anint iuotonrsiatilof hn xba.cl liorcoudl avtoi•n luAhpusersgeersbpdemaa sdlrs/rauh tfroioeioenmrn gudes sp oaierp ne anodgbtf hn OiacclTn Ccoryseoads ecse l••d lhAwPsourliateuhn r ts prhaf?oreeirr lgemnn scaaotongemcrynp?ilticya letioanves PTou rmpaoisnetain optimum nutrition using a feeding tube 6. RAAsTpIOirNaAteLE s:tInodmicaacthes c pornotpeenr tps.lacement.
history elements: calories,
samcuamatpiioponunltena.m itDnse iunnortgfia ntbdgiooi epnntre,a e rmagynno dcastna tlwcocyioo,u tmcmhae .lmn c Ciifunaamiellcr taimouli mcuzoas tntii ssob uneem saasevne aadnid ltaceiabaqlllu cefai ofttioer- itvnnaieH•••••id ceRmHSEMenaodeeroeeldcutaatn hheicdlatt yaetahilsn rltyas Mahhieio ul rolsinnespnsonaaeelp dadfleso ot/:rlsif reoraat svonetshaess.elhe xr dishpiMsony oedgcqaertueenaar-tnsceeaa ••d rlpvvAsTmneiiu rsttro oaaapismtudmmcpeyerhlssiiiennn ”so“umimss dCf,,noea wnclnirilacyatbg l itucaf eoisncriuo ,eei mdndmc g,rpi nialrtae o nranpta o,fl ohskra,f ee cr imlteaydsu tos bftt rl tboihmeoe die nbs cctloerereol.lad sAs .ea tdFn t edhtto iat•••Es oxFsMbdLaml etruinorma erterdc ciainiun niptiiit stnsagghsamre ct itoihnerrnr:ieneoxeg nae nan omreudrsiancnoeeutig--esuqds,;ecsu bfl aleaout eedidr yo inbticask e ttE•hhq aeOut s iritposo m-pm oaearsn csnehtads othgraosutrgich ttuhbee mouth or nares and into 7. Cfao.hlelUaocsswkpe i ifrpnoaHgrt e pti.nhrodep iicneasrtt opitrlu aptcaieopmne’ers nfpoto rul iascisyns:egs tshmee nmte othf ogda stric
the fetus for the growth and development of the skeleton iron is stored in the immature liver for use during thteem pfierarturset • Tap water or a water-soluble lubricant
• Avoid exhaustion b. Inject a small amount of air into the tube while
and teeth. 4 mCoomnmotnh Dsis coomff olrtisfe whileW teihghet G aliinver matuCrheildsbi rath nEdduc altiiovner enzymes • Syringe auscultating over the stomach; the nurse
Dsdwtaaoiitimluryyte e snp e;rtr hoovdenin uebgc testoss ,tot efwn sdoupa tearicrdiitydai olipltnyiro aomnld aiusllok cdu taasrn icladeyrs ems eorireflv kcic onpamglrcsomi doueufm ncm.dt sieT,l dkhc orafeonreer- acmroAsGtpCvsieiatoytnmVrIynlr:natTa :i idnc, tckl ediorafibspolgesaupmhamip itsetuteeieaseoelneea ersfdiyno,,n encrvns g:noeuuitd,mpi sdgerdiinatdyia eonnse icpgmhptee,nyn a/pcpec,oso ar in tra eesonR,n ft ispodioavD-er un Ac-ini erfsdFGE•••Noo anueIIFunncl.rnearncctse trorriagft eenriTlic-s aafingpg/ ssgs:Afreeoo hpcfroddwcfle iatabbeihcecrlll aoetehipdontn xddtgn.anie r:vfiro teveluo emlgwuaemdnemb aiononruftna nwn ut••• tosCwGbTmpm soirlior eeoatfptmhaatehcsioh oclse sb oes u sse dx: frs rl peA esi, e ,e s&c m fft,rr snhia Pehil/eic,ahvlarl andiacbrl xcibmoulootuaeaeaimrroett tieahnsfonl go n inporads/toup e sbsa.tiii tirsniotvnh e r1 et4hd ••••••Re t eIpPIEDeNinno sxrhmeoccrotpbycc:rrdoa eesrtotutuenieaai1orocrasnssiltnnaoiseedioeoae8gddinnnldi ca gpfs ea m trtttrolaos eiaagol st sfneetoasesxrtintmygeagurialeoe lnnu c enna geu esdesd by •S 12t e..p pWDHse aitnsehdr imhcaaintnoedr st p uaabnpede lrdenognt ghl orevqeus.ired by measuring c. Ossmhtboeotmtuahlaiodncd hha .iensa nxr- orata “yps rfiwalcomtoi ctsaohl ” vf oearrsi fetyhv eep rlaayi crfe eemendetiennrtgs. ,tT hbheuist
rHceleucaodlmeth lm e[geNunImdHee]ds, ,2d d0ua1rr1ikna g)g .r peOreetnhg nelera anrficycy hv (esNgoeuattraicobenlsea sol, f Id ncrasiltecidtiuu ftmreus ii tnos-f, 1fsot5GPsOfdaariyaaUtt sihir sgn:pme, up: fa trbrer:reoa, ei qlrucesunugknhuneeadokianc o/rgl,chgtir gndrydehae, e, ne msnnlaebasote g,acoany ltf cytu i,srbn ra,pisra meau aret1peftssh s,o ,t2w her- o wwmeoee•••m knBCiaPcnonaMotaudtns,iIekn e sDse sn ccA:entti ro ColSeeiuhnhdeHs gounf ppocaiin llasaasgetggnnio nsMnieean/ygP sm loa1ftt efo a9oodt uiaonnntd i( n•o ImbnCcnierrlaewtnhrdabasstoe,eg ret peanomai rbcsetatisrpn,rtuaeht e,r/ fptt1eyutlseapmdnee8 iscnt a go rofeo m, f2 gM7/d meadygiC,c/o dmiapnanlemyede,,ntary Care: fptrhooeimn ut m tbhbeeti lwnicoeusese n( Ft toihg te. h 2ee1n -ed1a9 ro)l.fo bthee a xnipdh tooi dth per omciedsws aaynd iotsir no nufaotesuonsg ufaesseetddrii cna ffget.eerd iinnigti atul bpela wcehmeenn ut soefd t fhoer ocoron--
insomnia • Ayurveda beneficial during
and nuts. 2001). Iron can be found in a variety of food sourc•e Sstre.s s Mmapnreaacgoennmceyenptt i o n p meraiosdsage, RATIONALE:Proper measurement determines the RATIONALE:Indicates proper placement.
light and aromatherapy, reflexology,
inRDdeiffceoirgevnnitziaiet des ifgruonms o adf isclcosommp floimcratstionas:y not beN• uSarosmiwneg f oIanosdrisg ehdte:c retahse airont a basodrptieonquate am• orAecluauxparnetisosntu, rsme i fnodro fnualnfuessesa-b aansde db aycokg a distance that the catheter is inserted.
iron are found in fortified• Id ernteifya podtenytia-l etnoviro-nemeantatl thcreeatsr eals, whitpeain beans,
bOopntei mmeizailn sgup Opluetmceonmtses—Teaching patients to avoid lseh•••••n rHSIPPnprRytifeepoOmeicenctMrtlilaoeasnnmmpee,possu ,iissa gasarbaopvnritdioaidnrnum apcruhn, ek jiudincee••• y.tWfOnA aoucb m Romecemiumlsbytbeieeba tnpyrrn lydeaeoiwso nf ic tanpaha ir rnnemPin sgghKk nac Uafovsae neuscc n,htsoyasoi greuc nftloloidinlmfrs ig criapea,nlcmnic eitan iivtcienora enasc seldb uedainn•sg E,n cbouO•se rapUbogtiesriemteh yf p ipdzr,reieebn cfnegodacn eOttcasueula pitnctcntiooemnrkv sceeasn,,r:teio ncos uton sperleinvgent 3. Nttuuorbteeer ’ntsh ebeala rm ctkhe eam snuaarrkere mos.ne n tth be yp fironxdiminagl tehned m oaf ntuhfeac- Rfiosksc wuitsh aon onro -s oar nfaesotgaystric tube
Bone meal, sometimes used as a calcium source, should be an•• dAPblas celennacteam opfr efevbitaa/la ,mb orcuvpeotmioe nnttain modertearattoege naic emffectosunts of iron a• Ussms eow kSinUgCe/sCmlEolSk.Sin pgSr coeogsrasmmat ioton e esdtruactaetgeie asbout 4. Lubricate the tube with tap water or a water-soluble There are some risks with an oro- or nasogastric tube. The liquid
avoided during pregnancy. This supplement is frequently of ptlahcenetae best food sources for iron include oy• Uwsosetm SeenB rIwRisTth p ,ar locgoorhaomrl uignsteea rdvisenonrtdioenrss tdou trrienagt lubricant. Follow manufacturer guidelines. from the feeding or medication may enter the lungs and possibly
pregnancy
contaminated with lead, a toxin that readily crosses the pla- meWahterse R(eseea.rcgh a.n,d lPriavctiecer M eaet:nd giblets)C,u laturnal Ddive rfsoity:rtified in•s Tteaachn hetal thc beoneofitsk of ebredastfeeding cause pneumonia. The feeding tubes may also cause the child
• Maternal smoking behavior influenced by need • Higher maternal anemia in RATIONALE:Lubrication eases catheter insertion.
cVenittaam anind Dca,n a rfeastu-lsto ilnu bhlieg hv ilteavmelisn i no bthtaei nfeetdus l.argely from chin•••e iAnPrMpg erernraceee•gtWong eeghaymtQinnnanto iaaaafvitm a eecntenecacoretlxtlhv ylt pns weowe hdsedarronoicst aeilmwtt.mi ietts io liani eoeretn3r fheann nnlyIbu s e aeeic- nmnwbnantuboeencsoefr mtieevrc ouixen-einraen ecblrt rulrconiipaeorirttsaneheeens s cdnpw esf aroPdteoettla Titlggm ol Sr h wianeDtosumindon risgsscefy iagtndemt rgoxihopi lisnnvttor oyiunemtis gos,e nr bn ycg an p(n •••e NeAlHAPrMionencmfiiwfeclgrlriuigxae-hceIseii aer ecoaoinnacrHussc csa ndvssiAeon i oetwbdsme acpw,e ,ocmifreraaeloo em ireitamngine2vcefdrron sdsaenDma nn y0iwR nmrsd,icn it/eta aT h aa1sfny i ddtc sdgahoiiio 2enetawlumnetn,v sosacee) umcyn ecec wde.ruuna ntfldltttets euuort,isra rfaA a liti llnfhl,crye h ai cralmnn a 2tms3 s.8c N••••••p aoDIDDIIdddmwiiieeernsss nnncccCouuutttiiia fffsssgyyynsssv scdYpaw buoaorsiobmnoeuprsgdce:emktoea,cf onr tnf eas ncsc te ioeiidgg pmfsinru st gtistecooo oo,hni onmbae d cenpnfa eo dnrtarer uevmtgtsorn eiiotaddiofne icnpcda ry etigonna unscey 5. Utnooswisneag,r tdtoh tweh aedr obdma tchinke ao onfct tc hhipaeun ttdh.,r ogaetn otlry, difi ruescint gth teh etube dnTIteia siausc csoiemhma pPf, ooaorrrrtte .av Tnnohttmes f iottuirn bpgea. rceannt sa tlsoo u bnedceormstae npdlu tghgee pdu, rcpaoussein ogf pthaein ,
consuming fortified milk or juice, fish oils, and dietary sup-
through a balanced diet, it is almost impossible to meet the feeding tube. Enteral tube feedings offer complete nutrition, but
plements, is important in the absorption and metabolism of
maternal daily requirements for iron without a dietary sup- children often need additional water flushes to provide for main-
calcium. During pregnancy and lactation, the RDA for vita- tenance fluid requirements. Parents must be able to recognize
plement. Consideration must be given, however, to the gas-
min D is 600 IU (15 mcg)/day. Severe maternal vitamin D NG tube signs that the NG tube is not functioning properly or may be dis-
trointestinal side effects of supplemental iron, which
deficiency has been associated with biochemical evidence inccolundcee cpotn Mstiapaptsio vni,s ubalallcyk stuamrrmy satroizoels t,h nea ruesleaat,i oannsdh iapbs- 2 1 pplaarceendts. Inf ethede ctoh ikldn oisw d ihsochwa rtgoe cdh ehcokm pel awceitmh ethnet, NadGm tuinbiset einr fpeleadce-,
of disordered skeletal homeostasis, congenital rickets, and
daommoinnagl cthraem mpionsgt . iTmhpeoser tsaindet ceoffnecctesp mtsa. yU esxea ctherebmat eto o t her ings, secure the NG tube to the child’s face, and recognize signs
fractures in the neonate. While there is insufficient evidence pregnancy-related gastrointestinal discomforts. Daily iron of intolerance to feedings.
for the recommendation for screening all pregnant women review the chapter content and better understand
supplementation is often initiated at around 12 weeks of
for vitamin D deficiency, it is important to educate women how to apply it in practice.
gestation to avoid compounding the nausea commonly
about the need for vitamin D–fortified foods or supplements
prevalent during the first trimester. Adequate water intake Documentation
(ACOG, 2011a; Harris, 2011). Fortified milk and ready-to-
helps to decrease constipation, and patients may take the Xiphoid process
eat cereals constitute the major food sources of vitamin D, iron at bedtime if abdominal discomfort is experienced 3 6/18/10 1300 8F nasogastric tube inserted in left nostril
which is also produced in the skin by the action of sunlight. Tip of NG tube
when taking iron between meals. A systematic review pub- without difficulty. Placement of the tube confirmed.
Women who do not include milk in their diets should be Umbilicus
lished by the Cochrane Collaboration (Pena-Rosas, De-
taught about other vitamin D sources such as cereals, egg Procedure Boxes provide step-by-step instructions Nasogastric tube secured.
Regil, Dowswell, & Viteri, 2012) shows that taking iron
yolks, liver, and fatty fish such as salmon, sardines, and trout. (and rationales) for performing common procedures. —D. Naccarini, RN
supplements one to three times per week is just as effective Figure 21-19 Nasogastric tube insertion measurement.
Sunscreens with a recommended SPF rating of 8 appear to
at preventing anemia as taking them every day, and the in-
block vitamin D–producing UV rays. In practice, however,
termittent dosing schedule is associated with fewer side
most people do not apply adequate amounts, cover all sun-
effects.
exposed skin, or reapply sunscreen regularly. Most likely, the
skin synthesizes some vitamin D even when it is protected by
sunscreen as typically applied (NIH, 2011b).
Nursing Insight—When teaching about iron
supplements
nursing insight boxes show you how
Cultural Diversity— Maternal Vitamin D
Deficiency Nurses can teach patients about substances known to decrease experienced nurses use their five senses to
the absorption of iron. Women should be taught to avoid con- gain a deeper understanding of the clinical
African Americans and other women with naturally dark skin suming bran, tea, coffee, milk, oxylates (found in Swiss chard situation or the patient’s condition.
whose melanin affects UV penetration are at the greatest risk and spinach), and egg yolk at the same time as they take the
for vitamin D deficiency. Women who habitually cover most iron supplement. Also, iron is best absorbed when taken be-
of their skin with clothing for religious or cultural purposes, tween meals with a beverage other than tea, coffee, or milk.
vegetarians, and those who live in northern latitudes with lim-
ited exposure to sunlight are also more likely to be deficient in
Vitamin C (ascorbic acid), important in tissue forma-
vitamin D. Because newborn vitamin D levels are largely de-
tion, also enhances the absorption of iron. Women who
pendent on maternal vitamin D status, infants of mothers with
take iron supplements should consume foods or beverages
or at high risk of vitamin D deficiency are also at risk for vita-
that contain vitamin C. Food sources rich in vitamin C in-
min D deficiency (ACOG, 2011a).
clude red and green sweet peppers, oranges, kiwi fruit,

3665_FM_i-lxx 01/05/15 2:04 PM Page vii
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3665_FM_i-lxx 05/05/15 3:55 PM Page ix
Maternal-Child
Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
SECOND EDITION
Susan L. Ward, PhD, RN
Professor of Nursing and Director of Nursing, Special Programs
Nebraska Methodist College
Omaha, Nebraska
Shelton M. Hisley, PhD, RNC, WHNP-BC
Associate Professor of Nursing (Retired)
University of North Carolina at Wilmington
Wilmington, North Carolina
Amy Mitchell Kennedy, MSN, RN, Associate Editor
Adjunct Faculty, AAS Registered Nursing Program
ECPI University: School of Health Science
Newport News, VA