Foundations of Maternal & Pediatric Nursing

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Foundations Foundations

of Maternal &

Pediatric Pediatric Nursing Nursing

Th ird Edition

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Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States

Foundations

of Maternal &

Pediatric Nursing

Th ird Edition

Lois White, ^{RN, PhD}

Former Chairperson and Professor Department of Vocational Nurse Education, Del Mar College, Corpus Christi, Texas

Gena Duncan, RN, MSEd, MSN

Former Associate Professor of Nursing, Ivy Tech Community College, Fort Wayne, Indiana

Wendy Baumle, ^{RN, MSN}

James A. Rhodes State College, School of Nursing, Lima, Ohio

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Lois White:

To my beloved husband, John, who is on his last great adventure and learning experience.

Gena Duncan:

To my husband, who gives me unconditional love and brings balance, calmness, and excitement to my life.

To Lois White, who modeled the role of an author and committed much of her life to this textbook.

To Wendy Baumle, for her hard work and dedication in developing this textbook.

Thanks.

To future nurses who are caring and competent.

Wendy Baumle:

This book is dedicated to my beloved family—Patrick, Taylor, Madeline, Blair, Connor, Janet, and Robert—for their love and support, to Juliet Steiner for inspiring me and for making a difference in my life, to Gena Duncan for her guidance and friendship, and to my friends, colleagues, and students for their support and valuable insight into today’s nursing education.

DEDICATIONS

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herein may be reproduced, transmitt ed, stored, or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitt ed under Section 107 or 108 of the 1976 United States Copyright Act, without the prior writt en permission of the publisher.

Library of Congress Control Number: 2010920488 ISBN-13: 9781428317765

ISBN-10: 1-428-31776-7

Delmar 5 Maxwell Drive

Clift on Park, NY 12065-2919 USA

Cengage Learning is a leading provider of customized learning solutions with offi ce locations around the globe, including Singapore, the United Kingdom, Australia, Mexico, Brazil, and Japan. Locate your local offi ce at: international.cengage.com/region

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To learn more about Delmar, visit www.cengage.com/delmar

Purchase any of our products at your local college store or at our preferred online store www.CengageBrain.com

Lois White, RN, PhD, Gena Duncan, RN, MSEd, MSN, and Wendy Baumle, RN, MSN

Vice President, Career and Professional Editorial:

Dave Garza

Director of Learning Solutions: Matt Kane Executive Editor: Steven Helba

Managing Editor: Marah Bellegarde Senior Product Manager: Juliet Steiner Editorial Assistant: Meghan E. Orvis

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Printed in the United States of America 1 2 3 4 5 6 7 12 11 10

Notice to the Reader

Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. Th e reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities described herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. Th e publisher makes no representations or warranties of any kind, including but not limited to, the warranties of fi tness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. Th e publisher shall not be li- able for any special, consequential, or exemplary damages resulting, in whole or part, from the readers’ use of, or reliance upon, this material.

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BRIEF CONTENTS

Unit 2: Nursing Care of the Client: Childrearing

6 Basics of Pediatric Care ... 170

7 Infants with Special Needs: Birth to 12 Months ... 189

8 Common Problems: 1 to 18 Years ...232

Unit 1: Nursing Care of the Client: Childbearing

1 Prenatal Care ...2

2 Complications of Pregnancy ...30

3 The Birth Process ...70

4 Postpartum Care ... 107

5 Newborn Care... 135

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v

UNIT 1 Nursing Care of the Client: Childbearing / 1 CHAPTER 1: PRENATAL CARE / 2

Introduction ...3

Preconception Education and Care ...3

Immunizations and Disease Status ...3

Medications ...3

Smoking, Alcohol, and Illicit Drugs ...3

Genetic Risk Factors ...4

Paternal Considerations ...4

Pregnancy ...4

Fertilization ...4

Implantation ...5

Amniotic Fluid ...5

Placenta and Umbilical Cord...5

Functions of the Placenta ...5

Fetal Development ...6

System Development ...8

Cardiovascular System ...8

Gastrointestinal System ...9

Musculoskeletal System ...9

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vi CONTENTS

Role Transition ...13

Partners’ Tasks ...13

Factors Affecting Psychological Response ...14

Body Image ...14

Financial Situation ...14

Cultural Expectations ...14

Emotional Security ...14

Support from Signifi cant Others ...14

Prenatal Education and Care ...14

Prenatal Care ...14

Initial Visit...14

Screening Tests ...18

Return Visits ...18

Anticipatory Guidance...20

Environmental Hazards ...20

Discomforts of Pregnancy ...20

Warning Signs ...20

Nutrition ...22

Self-Care ...23

Breast Care ...23

Personal Hygiene ...23

Activity/Rest ...24

Clothing ...24

Employment ...24

Travel ...24

Dental Care ...24

Sexual Activity ...24

Childbirth Education ...24

Nursing Process ...25

Assessment ...25

Nursing Diagnoses ...25

Planning/Outcome Identifi cation ...25

Nursing Interventions ...25

Evaluation ...25

Sample Nursing Care Plan: Prenatal Care ...25

Case Study ...27

CHAPTER 2: COMPLICATIONS OF PREGNANCY / 30

Assessment of Fetal Well-Being...31

Ultrasound ...31

Transabdominal Ultrasound ...32

Transvaginal Ultrasound ...32

Nonstress Test ...32

Vibroacoustic Stimulation Test ...33

Biophysical Profi le ...33

Modifi ed Biophysical Profi le ...33

Fetal Movements ...33

Biochemical Assessments ...33

Maternal Serum Alpha-Fetoprotein ...33

Estriol ...33

Human Placental Lactogen ...33

Amniocentesis ...33

Tests on Amniotic Fluid ...34

Chorionic Villi Sampling ...34

Contraction Stress Test ...34

Electronic Fetal Monitoring ...35

External (Indirect) Monitoring ...35

Internal (Direct) Monitoring ...35

Interpretations ...36

Hyperemesis Gravidarum ...37

Medical–Surgical Management ...37

Medical ...37

Pharmacological ...37

Diet ...37

Activity ...38

Nursing Management ...38

Assessment ...38

Subjective Data ...38

Objective Data ...38

Bleeding ...38

Abortion ...38

Medical ...39

Surgical ...39

Assessment ...39

Sample Nursing Care Plan: The Client Having a Spontaneous Abortion ... 40

Ectopic Pregnancy ...42

Medical ...42

Surgical ...42

Diet ...43

Activity ...43

Assessment ...43

Hydatidiform Mole ...43

Medical ...44

Surgical ...44

Activity ...44

Assessment ...44

Placenta Previa ...45

Effects on the Fetus/Neonate ...45

Medical ...45

Surgical ...45

Activity ...45

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Assessment ...46

Abruptio Placenta ...46

Medical ...47

Surgical ...47

Diet ...47

Activity ...47

Assessment ...47

Disseminated Intravascular Coagulation ...48

Medical ...48

Assessment ...49

Gestational Hypertension ...49

Mild Preeclampsia ...50

Severe Preeclampsia ...50

Eclampsia ...50

HELLP Syndrome ...50

Medical ...51

Surgical ...51

Diet ...51

Activity ...51

Assessment ...51

Chronic Medical Problems ...52

Diabetes Mellitus ...52

Pregnancy and Carbohydrate Metabolism ...52

Effects of Pregnancy on Diabetes ...52

Effects of Diabetes on Pregnancy ...53

Medical ...53

Surgical ...53

Diet ...53

Activity ...53

Assessment ...54

Chronic Hypertension ...54

Gestational Hypertension Superimposed on Chronic Hypertension ...54

Medical ...54

Diet ...55

Activity ...55

Assessment ...55

Heart Disease ...55

Medical ...55

Diet ...56

Activity ...56

Assessment ...56

Maternal Phenylketonuria ...56

Medical ...56

Diet ...56

Infections ...57

Torch Group ...57

Toxoplasmosis ...57

Medical ...57

Diet ...57

Activity ...57

Assessment ...58

Rubella ...58

Medical ...58

Assessment ...58

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viii CONTENTS

Cytomegalovirus ...59

Medical ...59

Herpes Genitalis (Herpes Simplex Virus Type 2) ...59

Medical ...59

Surgical ...59

Assessment ...60

HIV/AIDS ...60

Medical ...60

Diet ...60

Assessment ...60

Other Infections ...61

Hemolytic Diseases ...61

Rh Incompatibility ...61

Medical ...62

ABO Incompatibility ...63

Multiple Pregnancy ...63

Medical ...63

Surgical ...63

Diet ...63

Activity ...63

Substance Abuse ...63

Medical ...64

Assessment ...64

Preterm Labor ...65

Medical ...65

Assessment ...65

CHAPTER 3: THE BIRTH PROCESS / 70

Onset of Labor ...71

Theories Regarding Onset of Labor...71

Premonitory Signs of Labor ...72

Lightening ...72

Braxton Hicks Contractions ...72

Cervical Changes ...72

Bloody Show ...72

Rupture of Membranes ...72

Gastrointestinal Disturbance ...73

Sudden Burst of Energy ...73

Maternal Systemic Responses To Labor ...73

Renal System ...73

Fluid and Electrolyte Balance ...73

Immune System ...73

Neurological System ...74

Pain ...74

Variables Affecting Labor ...74

Passageway ...74

Pelvis ...74

Uterus ...75

Cervix ...75

Vagina ...75

Perineum ...75

Passenger ...75

Size ...75

Fetal Attitude ...75

Fetal Lie ...75

Fetal Presentation ...75

Position ...76

Engagement ...76

Station ...76

Fetal Position ...77

Powers ...77

Uterine Contractions...77

Maternal Pushing Efforts ...78

Psychological Response ...78

Stages of Labor ...79

First Stage: Dilation and Effacement ...79

Latent Phase ...79

Active Phase ...79

Transition Phase ...79

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Family Adaptation ...108

Mother’s Adaptation to Neonate ...108

Father/Partner’s Adaptation to Neonate—Nurse’s Role in Assessing with Adaptation ...109

Siblings’ Adaptation to Neonate ...109

Grandparents’ Adaptation to Neonate ...110

Maternal Physiologic Changes ...110

Reproductive System ...110

Uterus ...110

Cervix ...111

Vagina and Perineum ...111

Endocrine System ...112

Lactation ...112

Menstrual Cycle ...112

Breasts ...112

Vital Signs ...113

Cardiac Output ...113

Blood Volume ...113

Blood Values ...113

Coagulation ...113

Varicosities ...113

Urinary System ...114

Physical Changes ...114

Chemical Changes ...114

Joints, Ligaments, and Cartilage ...114

Abdominal Muscles ...114

Neurologic System ...114

Weight Loss ...114

Maternal Psychosocial Changes ...114

Expected Changes ...114

Rubin’s Restorative/Adaptive Phases ...114

Postpartum Blues ...115

Cesarean Birth ...115

Unexpected Changes ...115

Postpartum Depression...115

Postpartum Psychosis ...116

Infant with a Problem ...116

Discharge ...116

Assessment ...117

Breasts ...117

Uterus ...117

Bladder ...118

Bowels ...118

Lochia ...118

Episiotomy ...119

Lower Extremities and Homans’ Sign ...120

Bonding/Attachment ...120

Parenting ...120

Activity ...120

Comfort ...120

Self-Care ...120

Second Stage: Birth of Baby ...79

Mechanisms of Labor ...80

Third Stage: Delivery of Placenta ...81

Fourth Stage: Recovery ...82

Admission of Client In Labor ...83

Initial Assessment ...84

Assessment ...85

Nursing Diagnoses ...85

Planning/Outcome Identifi cation ...86

Nursing Interventions ...86

Continuing Assessment of Labor and Fetal Well-Being ...86

Providing Maternal Physical Care ...86

Assisting Client and Support Person ...88

Providing Pharmacological Comfort Measures...88

Risks of Labor and Birth ...90

Preterm Labor and Birth ...90

Premature Rupture of Membranes ...90

Dystocia ...91

Dysfunctional Labor ...91

Pelvic Structure Variations ...92

Fetal Variations ...92

Mother’s Responses ...93

Abnormal Duration of Labor ...93

Prolonged Labor ...93

Precipitate Labor/Precipitate Birth ...93

Prolapsed Cord ...94

Induction/Augmentation of Labor ...94

Induction of Labor ...94

Oxytocin Infusion ...94

Augmentation of Labor ...95

Obstetric Procedures ...95

Cesarean Birth ...95

Incisions ...96

Anesthesia ...96

Scheduled or Unscheduled Cesarean Birth ...96

Vaginal Birth after Cesarean ...97

Forceps-Assisted Birth ...97

Indications ...97

Application of Forceps ...97

Vacuum-Assisted Birth ...97

Immediate Infant/Mother Care ...97

Care of the Infant ...98

Airway ...98

Breathing/Circulation...98

Warmth ...98

Identifi cation ...98

Care of the Mother ...99

Sample Nursing Care Plan: The Client in Labor ...100

CHAPTER 4: POSTPARTUM CARE / 107

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x CONTENTS

Health Promotion ...122

Rh Immune Globulin ...122

Rubella Immunization ...122

Cesarean Birth ...122

Incision ...122

Respirations and Breath Sounds ...122

Abdomen and Bowel Sounds ...122

Fluid Intake ...122

Urine Output ...122

Pain ...122

Sample Nursing Care Plan: The Postpartum Client ...123

Complications ...125

Postpartum Hemorrhage ...125

Early Postpartum Hemorrhage ...125

Uterine Atony ...126

Retained Placental Fragments ...126

Lacerations of the Birth Canal ...126

Hematoma ...126

Late Postpartum Hemorrhage ...126

Medical ...127

Surgical ...127

Activity ...127

Assessment ...127

Infections ...128

Wound Infection ...128

Metritis ...128

Mastitis ...129

Urinary Tract Infection ...129

Medical ...129

Surgical ...129

Diet ...129

Activity ...129

Health Promotion ...130

Assessment ...130

Thromboembolic Conditions ...130

Medical ...130

Activity ...131

Assessment ...131

Disseminated Intravascular Coagulation ...131

CHAPTER 5: NEWBORN CARE / 135

Immediate Needs of the Newborn ...136

Airway ...136

Breathing ...136

Physical Factors ...137

Chemical Factors ...137

Thermal Factors ...137

Sensory Factors ...137

Circulation ...137

Pulmonary Blood Vessels ...137

Ductus Arteriosus ...137

Foramen Ovale ...137

Ductus Venosus...137

Warmth ...137

Heat Production ...137

Heat Retention ...138

Heat Loss ...138

Immediate Care of the Newborn ...139

Apgar Score ...139

Resuscitation ...139

Neutral Thermal Environment ...139

Identifi cation ...139

Parent/Infant Bonding ...139

Prophylactic Care ...139

Vitamin K ...139

Hepatitis B Vaccination ...139

Eye Prophylaxis ...140

Umbilical Cord Care ...140

Physical Characteristics of the Newborn ...140

Weight and Length ...140

Vital Signs ...141

General Appearance ...141

Skin ...141

Head ...141

Eyes ...141

Ears ...141

Neck ...141

Chest ...141

Abdomen ...141

Genitalia ...141

Back ...142

Extremities ...142

Common Variations In the Newborn ...142

Skin ...142

Jaundice ...142

Ecchymosis ...142

Milia ...142

Erythema Toxicum Neonatorum ...142

Telangiectactic Nevi ...142

Nevus Flammeus ...142

Nevus Vascularis ...142

Mongolian Spots ...143

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Breast Milk and Infant Formula Composition ...153

Breast Milk ...153

Infant Formula ...154

Feeding Method ...154

Breastfeeding ...155

Positions for Feeding ...155

Latching On ...155

Length of Feeding ...155

Bottle Feeding ...156

Bottles ...156

Formula Preparation ...156

Amount of Feeding ...156

Burping ...156

Pacifi ers ...156

Sample Nursing Care Plan: Newborn Infant ...156

Problems of the Newborn ...158

Hyperbilirubinemia ...158

Medical ...158

Surgical ...158

Diet ...159

Assessment ...159

Respiratory Distress ...159

Medical ...160

Assessment ...160

Cleft Lip/Palate ...161

Hydrocephalus ...161

Spina Bifi da ...161

Down Syndrome ...161

Talipes Equinovarus ...162

Infant of a Diabetic Mother ...162

Medical ...162

Diet ...162

Assessment ...163

Infant of an HIV-Positive Mother ...163

Infant of a Substance-Abusing Mother ...163

Medical ...164

Diet ...164

Assessment ...164

Head ...143

Molding ...143

Caput Succedaneum ...143

Cephalhematoma ...143

Eyes ...143

Ears ...144

Mouth ...144

Chest ...144

Genitalia ...144

Female ...144

Male ...144

Extremities ...144

Refl exes ...144

Rooting Refl ex...144

Sucking Refl ex ...144

Extrusion Refl ex ...145

Palmar Grasp Refl ex ...145

Plantar Grasp Refl ex ...145

Tonic Neck Refl ex ...145

Moro Refl ex ...145

Gallant Refl ex ...146

Stepping Refl ex ...146

Babinski’s Refl ex ...146

Crossed Extension Refl ex ...146

Placing Refl ex ...147

Behavioral Characteristics ...147

Periods of Reactivity ...147

First Period of Reactivity ...147

Sleep Period ...147

Second Period of Reactivity ...147

Behavioral States ...147

Sleep States ...147

Alert States ...148

Gestational Age ...148

Assessment of External Physical Characteristics ...148

Resting Posture ...148

Skin ...149

Lanugo ...149

Plantar Creases ...149

Breast ...149

Eye/Ear ...149

Male Genitals ...149

Female Genitals ...149

Neuromuscular Maturity ...149

Square Window ...149

Arm Recoil ...149

Popliteal Angle ...149

Scarf Sign ...149

Heel to Ear ...150

Gestational Age Relationship to Intrauterine Growth ...150

Sleeping Position ...150

First Bath and Cord Care ...151

Circumcision ...151

Procedure ...151

Nutrition ...153

Nutritional Needs of Newborn ...153

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xii CONTENTS

Surgical ...191

Laryngotracheobronchitis ...192

Medical ...192

Pneumonia ...193

Medical ...193

Respiratory Distress Syndrome ...193

Medical ...193

Cystic Fibrosis ...193

Medical ...194

Diet ...194

Assessment ...194

Sudden Infant Death Syndrome ...195

Congenital Cardiovascular Defects ...196

Surgical ...197

Diet ...197

Assessment ...197

Hematologic and Lymphatic Systems ...198

Hyperbilirubinemia ...198

Medical ...198

Iron-Defi ciency Anemia ...199

Assessment ...199

Diet ...199

Sickle-Cell Anemia ...200

Medical ...200

Phenylketonuria ...165

UNIT 2 Nursing Care of the Client: Childrearing / 169 CHAPTER 6: BASICS OF PEDIATRIC CARE / 170

Preparing the Child and Family for Hospitalization ...171

Admission ...172

Protection/Safety ...172

Pediatric Clients Experiencing Surgery ...174

Discharge/Discharge Planning...176

Pediatric Procedures ...176

Physical Assessment ...176

Growth Measurements ...176

Developmental Assessment ...181

Child Safety Devices ...181

Specimen Collection ...181

Urine ...181

Stool ...182

Blood ...182

Lumbar Puncture...183

Intake and Output ...183

Administration of Medications ...183

Approaches to Pediatric Clients ...183

Calculating Dosages for Children ...184

Oral Medications ...184

Intramuscular Injections ...185

Otic Medications ...185

Intravenous Medications ...185

The Dying Child ...185

Child ...185

Caregivers ...186

Siblings ...186

Nurse ...186

Sources of Support ...186

CHAPTER 7: INFANTS WITH SPECIAL NEEDS: BIRTH TO 12 MONTHS / 189

Otitis Media ...190

Medical ...191

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