NUR318 - Exam II - Maternal Health Nursing

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Chapter 8: Maternal and Fetal Nutrition

Chapter 8: Maternal and Fetal Nutrition

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Adequate Intakes (AIs)

Recommended nutrient intakes estimated to meet the needs of almost all healthy people in the population; provided for nutrients or age-group categories for which the available information is not sufficient to warrant establishing recommended dietary allowances

anthropometric measurements

Body measurements, such as height and weight

body mass index (BMI)

Method of calculating appropriateness of weight for height (BMI = weight/height2)

Dietary Reference Intakes (DRIs)

Nutritional recommendations for the United States, consisting of the recommended dietary allowances, adequate intakes, and tolerable upper intake levels; the upper limit of intake associated with low risk in almost all members of a population

intrauterine growth restriction (IUGR)

Fetal undergrowth from any cause

kcal

Kilocalorie; unit of heat content or energy equal to 1000 small calories

lactose intolerance

Inherited absence of the enzyme lactase

physiologic anemia

Relative excess of plasma leading to a decrease in hemoglobin concentration and hematocrit; normal adaptation during pregnancy

pica

Unusual oral craving during pregnancy (e.g., for laundry starch, dirt, red clay)

pyrosis

A burning sensation in the epigastric and sternal region from stomach acid (heartburn)

Recommended Dietary Allowances (RDAs)

Recommended nutrient intakes estimated to meet the needs of almost all (97%-98%) of the healthy people in the population

• Good nutrition before and during pregnancy helps prevent neonatal problems, such as low birth weight and prematurity.

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• Nutritional care during the preconception period and pregnancy includes nutrition assessment, diagnosis of nutrition-related problems or risk factors (such as diabetes, phenylketonuria, and obesity), intervention based on the dietary goals and plan, and evaluation.

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• If the mother is significantly underweight or overweight when pregnancy begins, maternal and fetal risks are increased.

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• During pregnancy, physiologic changes influence the need for additional nutrients.

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• The optimal rate of weight gain depends on the stage of pregnancy. Total maternal weight gain and the pattern of weight gain affect the pregnancy outcome.

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• Nutritional risk factors include adolescent pregnancy, multifetal pregnancy, frequent pregnancies, previous poor fetal outcome, poverty, nicotine use, alcohol or drug use, poor diet habits, problems with weight gain, and weight loss.

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• By 12 weeks of gestation, the pregnant woman should start taking 30 mg of ferrous iron daily. Depending on nutritional risk factors, a woman may need other supplements.

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• Moderate exercise during pregnancy improves muscle tone, which may shorten the course of labor, and promotes a sense of well-being.

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• Chronic conditions, such as diabetes mellitus, renal disease, liver disease, cystic fibrosis, seizure disorders, hypertension, and phenylketonuria, may affect a woman's nutritional status and dietary needs.

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• The only nutrition-related laboratory test most women need is a hematocrit or hemoglobin measurement to screen for anemia.

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• Nutrition-related discomforts of pregnancy include nausea and vomiting, constipation, and heartburn. Dietary adaptation can help ease these discomforts.

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Critical Thinking/Clinical Decision Making

Nutrition and the Overweight Pregnant Woman

Tamara, of African-American and Asian heritage, is 3 months pregnant and comes to her initial appointment for diagnosis and care. She appears to be overweight for her height. To provide optimal care for her, you plan to calculate her prepregnancy body mass index. When her pregnancy is confirmed, you are asked to plan a diet with Tamara that meets the minimum daily requirements and allows for growth of the pregnancy. You know the importance of including consideration of personal preferences and cultural factors in your plan. With Tamara, identify barriers to implementing the plan.

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1. Evidence—Is evidence sufficient to draw conclusions about an appropriate nutrition plan, taking into consideration personal preferences and cultural factors?

Yes. A dietary assessment using a food intake questionnaire should be conducted and a physical assessment of nutritional status performed. Based on these data, the desired pattern of weight gain during pregnancy, and a knowledge of characteristic food patterns of African-American and Asian people, planning can begin.

2. Assumptions—Describe the underlying assumptions about each of the following issues:
a. Dietary reference intakes for pregnancy and lactation
b. Indicators of nutritional risk in pregnancy
c. Daily food guide for pregnancy and lactation
d. Sources of calcium for women who do not drink milk

Assumptions.
a. A list of dietary reference intakes (RDIs) for pregnancy and lactation can be shared with Tanisha. Through discussion, you can determine whether Tanisha is ingesting adequate amounts of these important elements and whether supplementation of vitamins and minerals is necessary.
b. While reviewing indicators of nutritional risk in pregnancy with Tanisha, problem areas can be identified, and recommendations for change provided as needed.
c. The daily food guide for pregnancy and lactation can be shared with Tanisha. It can provide a basis for planning appropriate menus to provide the necessary nutrients and avoid consuming more energy (calories) than is desired.
d. As someone of African-American and Asian heritage, Tanisha may be lactose intolerant and may need sources of calcium other than milk. Through careful questioning, her lactose status can be determined and counseling can be provided about nonmilk sources of calcium.

3. What implications and priorities for nursing care can be drawn at this time?

As part of her prenatal care, Tanisha (and all pregnant women) should receive nutrition counseling. Tanisha is currently overweight. Although reduction diets may be contraindicated in pregnancy, Tamara can be assisted to plan menus that allow a slow but adequate weight gain to support growth of the pregnancy and the fetus and avoid excess weight gain.

4. Does the evidence objectively support your conclusion?

Yes, there is ample evidence about DRIs in pregnancy and lactation. Nutrition counseling should be part of the plan of care for Tanisha.

5. Do alternative perspectives to your conclusion exist?

Tanisha could have metabolic problems, including diabetes mellitus, that contribute to her weight. Ethnic and cultural patterns of eating and fast food choices could also be factors. Enlisting the support of her family would likely be helpful in planning appropriate meals.

1. When planning a diet with a pregnant woman, the nurse's first action would be to:
A. Review the woman's current dietary intake.
B. Teach the woman about the food pyramid.
C. Caution the woman to avoid large doses of vitamins, especially those that are fat-soluble.
D. Instruct the woman to limit the intake of fatty foods.

A. Review the woman's current dietary intake.

Reviewing the woman's dietary intake as the first step will help to establish whether she has a balanced diet or whether changes in the diet are required. Teaching about the food pyramid is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does. Cautioning the woman to avoid large doses of vitamins is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does. Instructing the woman to limit intake of fatty foods is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does.

2. A pregnant woman with a body mass index (BMI) of 22 asks the nurse how much weight she should be gaining during pregnancy. The nurse's best response would be to tell the woman that her pattern of weight gain should be approximately:
A. A pound a week throughout pregnancy.
B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.
C. A pound a week during the first two trimesters, then 2 pounds per week during the third trimester.
D. A total of 25 to 35 pounds.

B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.

A pound a week is not the correct guideline during pregnancy. A BMI of 22 represents a normal weight. Therefore, a total weight gain for pregnancy would be about 25 to 35 pounds or about 2 to 5 pounds in the first trimester and about 1 pound per week during the second and third trimesters. A pound per week the first two trimesters and 2 pounds per week the third trimester are not accurate guidelines for weight gain during pregnancy. The total weight gain of 25 to 35 pounds is correct, but the pattern of weight gain needs to be explained.

3. A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent episodes of nausea during the day with occasional vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman:
A. Drink warm fluids with each of her meals.
B. Eat a high-protein snack before going to bed.
C. Keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed.
D. Schedule three meals and one mid-afternoon snack a day.

B. Eat a high-protein snack before going to bed.

Fluids should be taken between (not with) meals to provide for maximum nutrient uptake in the small intestine. A bedtime snack of slowly digested protein is especially important to prevent the occurrence of hypoglycemia during the night that would contribute to nausea. Dry carbohydrates such as plain toast or crackers are recommended before getting out of bed. Adding peanut butter would not be helpful. Eating small, frequent meals (about five or six each day) with snacks helps to avoid a distended or empty stomach, both of which contribute to the development of nausea and vomiting.

4. A pregnant woman's diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. The nurse would be most concerned about this woman's intake of:
A. Calcium.
B. Protein
C. Vitamin B12.
D. Folic acid.

C. Vitamin B12.

This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12.

5. A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned that during and after tennis matches this woman consumes:
A. Several glasses of fluid.
B. Extra protein sources such as peanut butter.
C. Salty foods to replace lost sodium.
D. Easily digested sources of carbohydrate.

A. Several glasses of fluid.

If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise, because dehydration can trigger premature labor. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Extra protein would not be needed. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. It would not be necessary to replace lost sodium. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Adding easily digested carbohydrate sources would not be necessary.

6. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with:
A. Spina bifida.
B. Intrauterine growth restriction.
C. Diabetes mellitus.
D. Down syndrome.

B. Intrauterine growth restriction.

Spina bifida is not associated with inadequate maternal weight gain. Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction. Diabetes mellitus is not associated with inadequate maternal weight gain. Down syndrome is not associated with inadequate maternal weight gain.

7. Which minerals and vitamins usually are recommended to supplement a pregnant woman's diet?
A. Fat-soluble vitamins A and D
B. Water-soluble vitamins C and B6
C. Iron and folate
D. Calcium and zinc

C. Iron and folate

Fat-soluble vitamins should be supplemented as a medical prescription, because vitamin D might be needed for lactose-intolerant women. Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B6 is prescribed only if the woman has a very poor diet. Iron generally should be supplemented during pregnancy, and folic acid supplements often are needed because folate is so important to the growing fetus. Zinc is sometimes supplemented during pregnancy. Most women get enough calcium.

8. With regard to nutritional needs during lactation, a maternity nurse should be aware that:
A. The mother's intake of vitamin C, zinc, and protein can be lower than during pregnancy.
B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.
C. Critical iron and folic acid levels, higher than during pregnancy, must be maintained to ensure the health of the infant.
D. Lactating women can go back to their prepregnant calorie intake.

B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.

Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. A lactating woman needs to avoid consuming too much caffeine. The recommendations for iron and folic acid are somewhat lower during lactation. Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.

9. When counseling a patient about getting enough iron in her diet, the maternity nurse should tell her that:
A. Milk, coffee, and tea aid iron absorption if consumed at the same time as iron.
B. Iron absorption is inhibited by a diet rich in vitamin C.
C. Iron supplements are permissible for children in small doses.
D. Constipation is common with iron supplements.

D. Constipation is common with iron supplements.

The beverages listed inhibit iron absorption when consumed at the same time as iron. Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die. Constipation can be a problem when iron intake is increased.

10. After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your instructions so you can assess her understanding of the instructions given. Which statement indicates that she understands the role of protein in her pregnancy?
A. "Protein will help my baby grow."
B. "Eating protein will prevent me from becoming anemic."
C. "Eating protein will make my baby have strong teeth after he is born."
D. "Eating protein will prevent me from being diabetic."

A. "Protein will help my baby grow."

Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in diabetics; protein is one nutritional factor to consider, but this is not the primary role of protein intake.

11. Obstetricians today are seeing more morbidly obese pregnant women (those that weigh 400 pounds or greater). A new medical subspecialty referred to as __________ obstetrics has subsequently arisen.

Bariatric

To manage the conditions of morbidly obese pregnant women and to meet their logistical needs, the subspecialty of bariatric obstetrics has been developed. Extra wide BP cuffs, surgical tables and scales that can hold these patients are necessary to deliver safe patient care. Special techniques for ultrasound and longer surgical instruments are also required.

Chapter 10: Management of Discomfort

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analgesia

Absence of pain without loss of consciousness

anesthesia

Partial or complete absence of sensation with or without loss of consciousness

counterpressure

Pressure applied to the sacral area of the back during uterine contractions

effleurage

Gentle stroking used in massage, usually on the abdomen

epidural block

Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space

epidural blood patch

A patch formed by a few milliliters of the mother's blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal or epidural block; its purpose is to relieve headache associated with leakage of spinal fluid

gate-control theory of pain

Pain theory used to explain the neurophysiologic mechanism underlying the perception of pain: the capacity of nerve pathways to transmit pain is reduced or completely blocked by using distraction techniques

local perineal infiltration anesthesia

Process by which a local anesthetic medication is deposited within the tissue to anesthetize a limited region of the body

neonatal narcosis

Central nervous system depression in the newborn caused by an opioid (narcotic); may be signaled by respiratory depression, hypotonia, lethargy, and delay in temperature regulation

opioid (narcotic) agonist analgesics

Medications that relieve pain by activating opioid receptors

opioid (narcotic) agonist-antagonist analgesics

Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal or newborn respiratory depression

opioid (narcotic) antagonists

Medications used to reverse the central nervous system depressant effects of an opioid, especially respiratory depression

pudendal nerve block

Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region

spinal anesthesia (block)

Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifth lumbar interspace

systemic analgesia

Pain relief induced when an analgesic is administered parenterally (e.g., subcutaneous [SC], intramuscular [IM], or intravenous [IV] route) and crosses the blood-brain barrier to provide central analgesic effects

• The way each woman perceives or interprets the pain of childbirth is influenced by physical, emotional, psychosocial, cultural, and environmental factors.

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• The gate-control theory of pain helps explain how the pain-relief techniques taught in childbirth preparation classes work.

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• Effective nonpharmacologic techniques for managing discomfort include focusing and relaxation, breathing techniques, and water therapy.

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• Used together, pharmacologic and nonpharmacologic measures increase pain relief and create a more positive labor experience for the woman and her family.

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• A woman who experiences a prolonged latent phase of labor and needs to decrease anxiety or promote sleep may be given a sedative.

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• Analgesic drugs used for the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists.

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• Opioid agonist analgesics relieve severe, persistent, or recurrent pain.

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• In appropriate doses, opioid agonist-antagonist analgesics provide adequate analgesia without causing significant respiratory depression in the mother or neonate.

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• Opioid agonist-antagonist analgesics are not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms in both the mother and her newborn.

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• Opioid antagonists, such as naloxone (Narcan), can reverse opioid effects, especially respiratory depression.

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• The nurse must understand the expected effects, adverse reactions, and methods of administration of the drugs given to the mother.

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• During spinal and epidural nerve blocks, the mother's fluid balance must be maintained.

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• Using epidural anesthesia and analgesia is the most effective pharmacologic method for relieving the pain of labor. In the United States, it is the most commonly used method.

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• General anesthesia is rarely used for vaginal birth but may be used for cesarean birth.

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Critical Thinking/Clinical Decision Making

Laboring Without an Epidural
Jamie is a 16-year-old G1 P0 who has been admitted with severe preeclampsia (HELLP syndrome) at 34 weeks of gestation. Jamie's physician plans to induce labor and anticipates a vaginal birth. Jamie has not attended any childbirth preparation classes and has been planning to have an epidural for labor and birth. Unfortunately, because her platelet count is very low (28,000), the anesthesia care provider refuses to place an epidural block. Jamie bursts into tears and says, "I can't make it through labor without an epidural! It's going to hurt too much! Help me!!

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1. Evidence—Is evidence sufficient to support the anesthesia care provider's decision to avoid epidural anesthesia for Jamie?

Yes. Jamie's platelet count of 28,000 is considered very low. Because of her thrombocytopenia Jamie is at risk for excessive bleeding if a blood vessel were to be damaged during insertion of the epidural catheter. Bleeding in the epidural space could cause the formation of a hematoma that might compress the cauda equina or the spinal cord and lead to serious CNS complications.

2. Assumptions—What assumptions can be made about the following methods for relieving pain during labor that would likely be available to Jamie?

a. Breathing and relaxation techniques
b. Application of heat and cold
c. Intradermal water block
d. Systemic analgesia

Assumptions.
a. Breathing techniques provide distraction, thereby reducing the perception of pain and helping Jamie maintain control throughout contractions. In the first stage of labor, such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. This lessens discomfort generated by friction between the uterus and abdominal wall during contractions. Because the muscles of the genital area also become more relaxed, they do not interfere with fetal descent. Although Jamie has had no prior preparation, she can be given instruction in simple breathing and relaxation techniques early in labor and will likely find these techniques to be helpful.
b. Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Cold application such as cool cloths or ice packs applied to the back, the chest, and/or the face during labor may be effective in increasing comfort when the woman feels warm. They may also be applied to areas of pain. Cooling relieves pain by reducing the muscle temperature and relieving muscle spasms. Heat and cold may be used alternately for a greater effect.
c. An intradermal water block involves the injection of small amounts of sterile water into four locations on the lower back to relieve back pain. It is simple to perform and is effective in early labor and in an effort to delay the initiation of pharmacologic pain relief measures. Relief of back pain for up to 2 hours has been reported. Effectiveness of this method is probably related to the mechanism of counterirritation.
d. Systemic analgesics cross the maternal blood-brain barrier to provide central analgesic effects. They also cross the placenta and are transferred to the fetus. Effects on the fetus and newborn can be profound (e.g., respiratory depression, decreased alertness, delayed sucking), depending on the characteristics of the specific systemic analgesic used, the dosage given, and the route and timing of administration. Intravenous (IV) administration is preferred to intramuscular (IM) administration because the medication's onset of action is faster and more predictable; as a result, a higher level of pain relief usually occurs with smaller doses. Ideally, birth should occur less than 1 hour or more than 4 hours after administration of systemic analgesia so that neonatal CNS depression is minimized.

3. What implications and priorities for nursing care can be drawn at this time?

The nurse's priority at this time is to do everything possible to keep Jamie comfortable during labor and assist her in achieving a satisfying birth experience, even though she will not be able to use her desired method of pain relief. Jamie can be informed that there are many methods for relieving pain in labor other than epidural anesthesia, and that we will keep trying until we find the methods that work best for her. Jamie's satisfaction with her labor and birth experience will be determined in large part by the quality of support and interaction she receives from her caregivers. Therefore, it is critical that the nurse, along with any support persons present, remains at the bedside to provide assistance in coping with each contraction. The nurse may need to try a variety of nonpharmacologic methods of pain relief in order to identify those that are most effective for Jamie.

4. Does the evidence objectively support your conclusion?

Yes. Many studies done over the years have shown that there are many nonpharmacologic methods available to effectively relieve labor pain.

5. Do alternative perspectives to your conclusion exist?

Yes. Although there are many nonpharmacologic methods that effectively relieve labor pain, epidural anesthesia and analgesia is the most effective pharmacologic pain relief method for labor that is currently available. As a result, it is the most commonly used method for relieving pain during labor in the United States, and its use has been increasing. Currently, nearly two thirds of American women giving birth choose epidural analgesia.

1. A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to:

A. Encourage the woman to breathe more slowly.
B. Help the woman breathe into a paper bag.
C. Turn the woman on her side.
D. Administer a sedative.

B. Help the woman breathe into a paper bag.

Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level. Turning her on her side would not solve this problem. The side-lying position would be appropriate for supine hypotension. Administration of a sedative could lead to neonatal respiratory depression because this woman, being in the transition phase, is nearing the birth process.

2. A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?

A. Meperidine (Demerol)
B. Promethazine (Phenergan)
C. Butorphanol tartrate (Stadol)
D. Nalbuphine (Nubain)

A. Meperidine (Demerol)

Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor. Promethazine is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Butorphanol tartrate is an opioid agonist-antagonist analgesic. Nalbuphine is an opioid agonist-antagonist analgesic.

3. A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:

A. Counterpressure against the sacrum.
B. Pant-blow (breaths and puffs) breathing techniques.
C. Effleurage.
D. Conscious relaxation or guided imagery.

A. Counterpressure against the sacrum.

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Breathing techniques are usually helpful during contractions because they provide distraction; they are not necessarily targeted at back pain. Effleurage is usually helpful for relieving pain from contractions per the gate-control theory. Conscious relaxation or guided imagery techniques are usually helpful during contractions because they provide the opportunity to focus on a more pleasant situation; they are not targeted specifically toward back pain.

4. Nurses should be aware of the differences experience can make in how labor pain is perceived, such as:

A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
B. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor.
C. Women with a history of substance abuse experience more pain during labor.
D. Multiparous women have more fatigue from labor and therefore experience more pain.

A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

5. With regard to breathing techniques used by a woman during labor, maternity nurses should be aware that:

A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
B. By the time labor has begun, it is too late for instruction in breathing and relaxation.
C. Controlled breathing techniques are most difficult to adhere to near the end of the second stage of labor.
D. The patterned-paced breathing technique can help prevent hyperventilation.

A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Providing instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult to adhere to in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

6. With regard to systemic analgesics administered during labor, nurses should be aware that:

A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier.
B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
C. Intramuscular administration (IM) is preferred over intravenous (IV) administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.

Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

7. With regard to spinal and epidural (block) anesthesia, nurses should know that:

A. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
B. A high incidence of after-birth headache is seen with spinal blocks.
C. Epidural blocks allow the woman to move freely.
D. Spinal and epidural blocks are never used together.

B. A high incidence of after-birth headache is seen with spinal blocks.

Spinal blocks may be used for vaginal births, but the woman must be assisted while she is in labor. A high incidence of after-birth headache can occur; headaches may be prevented or mitigated to some degree by a number of methods. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

8. Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the patient's blood pressure if hypotension occurs? Choose all that apply.

A. Place the woman in a supine position.
B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.
E. Perform a vaginal examination.

B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.

Placing the woman in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. A sterile vaginal examination has no bearing on maternal blood pressure.

Chapter 13: Maternal Physiologic Changes

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afterpains (afterbirth pains)

Painful uterine cramps that occur intermittently for approximately 2 or 3 days after birth and that result from contractile efforts of the uterus to return to its normal involuted condition

autolysis

The self-destruction of excess hypertrophied tissue

diastasis recti abdominis

Separation of the two rectus muscles along the median line of the abdominal wall

involution

Return of the uterus to a nonpregnant state after birth

lochia

Vaginal discharge during the puerperium consisting of blood, tissue, and mucus

lochia alba

Thin, yellowish to white, vaginal discharge that follows lochia serosa on approximately the tenth day after birth and that may last from 2 to 6 weeks postpartum

lochia rubra

Red, distinctly blood-tinged vaginal flow that follows birth and lasts 2 to 4 days

lochia serosa

Serous, pinkish brown, watery vaginal discharge that follows lochia rubra until approximately the tenth day after birth

pelvic relaxation

Lengthening and weakening of the fascial supports of pelvic structures

puerperium

Period between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state; fourth trimester of pregnancy

subinvolution

Failure of the uterus to reduce to its normal size and condition after pregnancy

• The time between birth and the return of the reproductive organs to their nonpregnant state is called the postpartum period, the puerperium, or the fourth trimester of pregnancy.

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• Involution, the process of returning the uterus to its nonpregnant state, begins immediately after placental expulsion.

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• The most common causes of subinvolution, the failure of the uterus to return to a nonpregnant state, are retained placental fragments and infection.

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• During the first 2 hours after birth, the amount of uterine discharge, called lochia, should be similar to the amount during a heavy menstrual period.

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• After placental expulsion, estrogen and progesterone levels decrease dramatically, triggering anatomic and physiologic changes.

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• In women who breastfeed, ovulation may be delayed for a long period of time.

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• After childbirth, total blood volume declines by about 16%, resulting in transient anemia.

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• Vessel damage, immobility, and elevated levels of coagulation factors during the immediate postpartum period predispose the woman to thromboembolism, especially after a cesarean birth.

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• Normally, few changes in vital signs occur after birth.

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• Kidney function returns to normal within 1 month after birth.

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• Pregnancy-induced hypervolemia allows most women to tolerate considerable blood loss during childbirth.

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Critical Thinking/Clinical Decision Making
Assessment of Postpartum Bleeding

You are the nurse assigned to care for Margarita, a G9 P9 who gave birth vaginally 1 hour ago to twins. Twin A weighed 7 pounds, 4 ounces, and Twin B weighed 6 pounds, 12 ounces. Margarita did not have an episiotomy and sustained no lacerations requiring repair. You are at the nurse's station when Margarita calls and asks for her nurse to "come quick!" When you arrive in her room, you find Margarita lying in a puddle of blood. The disposable pad underneath her, as well as Margarita's perineal pad, are completely soaked with blood.

...

1. What other immediate assessment is necessary to determine the cause and management of Margarita's excessive bleeding?

The most likely cause of Margarita's excessive bleeding is uterine atony. Therefore, the nurse's first assessment is to palpate Margarita's uterus. If the uterine fundus initially feels boggy rather than firm and well-contracted, uterine atony is confirmed as the probable cause of the excessive bleeding.

2. What assumptions can be made about the following issues:
a. Normal amount of lochia expected at this time (1 hour after birth)
b. Margarita's risk factors for uterine atony
c. Immediate nursing interventions for Margarita
d. Other possible causes for Margarita's excessive bleeding

Assumptions:
a. For the first 2 hours after birth, the amount of lochial flow should be approximately that of a heavy menstrual period. If Maria is lying in a puddle of blood and both the disposable pad underneath her and her perineal pad are completely soaked, she is obviously bleeding excessively.
b. Margarita has at least two risk factors for uterine atony. She is a grand multipara (G9 P9). She has also given birth to twins whose combined birthweight is 14 pounds.
c. Once uterine atony is confirmed, the nurse should continue to massage Margarita's fundus until it feels firm, like a hard ball. If an IV is already in place, the rate should be increased to provide additional volume. The intravenous fluid should contain oxytocin to further encourage uterine contraction. Next, vital signs should be obtained, especially blood pressure and heart rate. While obtaining vital signs, the nurse will also assess Margarita's skin temperature and mental status.
d. Other possible causes for Margarita's excessive bleeding include retained placental fragments or membranes or undiscovered, and thus unrepaired, genital tract lacerations.

3. Using the situation-background-assessment-recommendation (SBAR) technique, how would you report to Margarita's health care provider about her current status?

S: Margarita H., in Room 312, has excessive vaginal bleeding. Her underpad and perineal pad are both completely soaked, and she is lying in a puddle of blood.
B: Margarita is a G9 P9. She gave birth vaginally 1 hour ago to twins with a combined birthweight of 14 pounds. Margarita did not have an episiotomy and sustained no lacerations requiring repair.
A: Margarita's uterus was initially boggy to palpation, but firmed after fundal massage. Her bleeding has now decreased. Her most recent vital signs are BP 110/50, pulse 100, rate 22, temp 36.8° C. Her skin feels cool and dry. She is alert and oriented. An intravenous infusion of 500 ml D5LR with 30 units of oxytocin added is currently running at 50 ml per hour. I have just changed her underpad and perineal pad.
R: Please come ASAP to evaluate this patient for other sources of bleeding. In the meantime, do you want her to receive any other medications? Do you want to order a stat hematocrit or hemoglobin?

4. Does the evidence objectively support your conclusion?

Yes. Margarita's excessive bleeding was likely the result of uterine atony, probably caused by the huge expansion of her uterus necessary for her to give birth to two normal-sized term babies. Also, because Margarita is a grand multipara, her uterus will most likely not contract postpartum as well as it would if she had only given birth once or twice before.

5. Do alternative perspectives to your conclusion exist?

Uterine atony is the most likely cause of Margarita's excessive bleeding. However, other possible causes of postpartum hemorrhage such as retained placental fragments or membranes or unrepaired genital tract lacerations need to be ruled out.

1. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be:

A. Presence of soft, nontender colostrum.
B. Leakage of milk at let-down
C. Swollen, warm, and tender on palpation.
D. A few blisters and a bruise on each areola.

A. Presence of soft, nontender colostrum.

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.
Leakage of milk occurs around day 2 or 3. Engorgement occurs at day 2 or 3 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

2. A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

A. Urinary tract infection.
B. Excessive uterine bleeding.
C. A ruptured bladder.
D. Bladder wall atony.

B. Excessive uterine bleeding.

A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

3. Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter."
B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles."
C. "I will not have a menstrual cycle for 6 months after childbirth."
D. "My first menstrual cycle will be heavier than normal and then will be light for several months after."

B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles."

She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. Saying the first menstrual cycle will be heavier than normal and the subsequent three or four cycles will return to prepregnant volume is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

4. Which description of postpartum restoration or healing times is accurate?

A. The cervix shortens, becomes firm, and returns to form within a month postpartum.
B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.
C. Most episiotomies heal within a week.
D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.

The cervix regains its form within days; the cervical os may take longer to return to form. The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

5. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:

A. Wear a snug, supportive bra.
B. Allow warm water to soothe the breasts during a shower.
C. Express milk from breasts occasionally to relieve discomfort.
D. Place absorbent pads with plastic liners into her bra to absorb leakage.

A. Wear a snug, supportive bra.

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.

6. With regard to afterbirth pains, nurses should be aware that these pains are:

A. Caused by mild, continuous contractions for the duration of the postpartum period.
B. More common in first-time mothers.
C. More noticeable in births in which the uterus was overdistended.
D. Alleviated somewhat when the mother breastfeeds.

C. More noticeable in births in which the uterus was overdistended.

The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist throughout the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

7. Postbirth uterine/vaginal discharge, called lochia:

A. Is similar to a light menstrual period for the first 6 to 12 hours.
B. Is usually greater after cesarean births.
C. Will usually decrease with ambulation and breastfeeding.
D. Should smell like normal menstrual flow unless an infection is present.

D. Should smell like normal menstrual flow unless an infection is present.

Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.

8. Although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not. The new mother may notice a permanent increase in her shoe size. True or False?

True

9. Changes in the maternal immune system during the postpartum period account for the profuse diaphoresis that new mothers experience. True or False?

False

Chapter 14: Nursing Care of the Family during the Fourth Trimester

...

couplet care

One nurse, educated in both maternal and newborn care, functions as the primary nurse for both mother and neonate (also known as mother-baby care or single-room maternity care)

engorgement

Swelling of the breast tissue brought about by an increase in blood and lymph supplied to the breast, occurring as early milk (colostrum) transitions to mature milk, at approximately 72 to 96 hours after birth

uterine atony

Relaxation of uterine muscle possibly leading to excessive postpartum bleeding and postpartum hemorrhage

warm line

A help line, or consultation service, for families to access, most often for support of newborn care and postpartum care after hospital discharge

• Postpartum care is family-centered.

...

• Nursing care in the early postpartum period includes helping the mother rest and recover, assessing her physiologic and psychologic adaptation, preventing complications, teaching self-care and infant care, and supporting the mother and her partner as they make the transition to parenthood.

...

• The nurse starts preparing the new mother for discharge at their first postpartum contact.

...

• The care plan includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort, and safety measures to prevent injury and infection.

...

• In the postpartum period, nursing interventions include preventing excessive bleeding, bladder distention, and infection; relieving pain and discomfort; and promoting or suppressing lactation.

...

• The most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.

...

• Common causes of discomfort include pain from uterine contractions (afterpains), perineal lacerations, episiotomy, hemorrhoids, sore nipples, and breast engorgement.

...

• Early ambulation is associated with a reduced incidence of venous thromboembolism.

...

• The mother should void spontaneously within 6 to 8 hours after giving birth.

...

• To help meet the psychosocial needs of a new mother, the nurse assesses the parents' reactions to the birth experience, feelings about themselves, and interactions with the baby and other family members.

...

• A woman's cultural background strongly influences her behavior during the postpartum period.

...

• After uncomplicated vaginal births, women are commonly scheduled for a 6-week postpartum follow-up examination.

...

• Early discharge classes, telephone follow-up, home visits, warm lines, and support groups can facilitate physiologic and psychologic adjustments in the postpartum period.

...

Critical Thinking/Clinical Decision Making
Cultural Influences during the Postpartum Period

Mingyu is a 29 year old from China who gave birth to her first child last evening. Her husband is completing postdoctoral study at the local university. Both Mingyu and her husband speak some English, although he is more fluent than she is. Her mother and father have come from China to be with her for 3 months. When the nurse enters the room, she notices immediately that the room temperature is rather warm and Mingyu is lying in bed with several layers of covers pulled up to her neck. She also has a blanket around her head. She has eaten nothing from the breakfast tray. The nursing assistant had reported that Mingyu refused to shower this morning. Although Mingyu's chart indicates that she intends to breastfeed, she requests formula for her baby.

...

1. Evidence—Is evidence sufficient to draw conclusions about the cultural beliefs of Asians as they relate to the postpartum period and breastfeeding?

Yes. Potential sources of information include journal articles, books, and interviews with women who are members of that cultural group. Information regarding how traditional Asian beliefs may be adapted by women who immigrate to other countries is also available from these sources.

2. Assumptions—What assumptions can be made about the following issues?
a. Culturally appropriate diet, activity, and hygiene for the postpartum Asian woman
b. Providing appropriate care for the newborn, including breastfeeding, in the Asian culture
c. Role of other family members and friends in providing care to the postpartum woman and newborn
d. Difficulty in establishing lactation if breastfeeding is not begun immediately

Assumptions.
a. In the postpartum period, Asian women are concerned with maintaining balance between hot and cold within the body and in the environment. Blood is considered "hot," so when blood is lost through childbirth, she is considered to be in a "cold" state. A major focus in the postpartum period is keeping the new mother warm. Asian women typically prefer warm foods and hot drinks after giving birth and refuse anything cold. Warm food and drinks help to restore balance in the woman's body by facilitating the return of the "hot" state. The environmental temperature is kept warm; even in summer, the air conditioning is turned off and windows are closed. The postpartum woman is expected to stay in bed to prevent cold air from entering her body. Baths, showers, or washing hair are not permitted. During the 30-day confinement period after birth, the new mother is not to be walking about and cannot leave her home. She is expected to take a passive role. Household tasks are done by female relatives or live-in helpers.
b. Because of the prevalent belief among Asians that the mother should rest and remain in bed to protect herself immediately after childbirth, routine baby care is usually provided by another female. In several cultures, including Asian cultures, colostrum is viewed as unnecessary and unhealthy for newborns. Breastfeeding is begun only several days after birth, when the "true milk" has come in. Before that time, babies may be fed prelacteal food. Asian parents often request infant formula for their infant while they are in the hospital.
c. In many cultures, female family members and friends play an essential role in providing care for the new mother and baby immediately after birth. In the Asian culture, new mothers observe specific diet and activity restrictions for several weeks. Following these traditional cultural practices in a different country may prove to be extremely difficult if family members or friends are not available. In the home country, males are often not expected to assist in caring for new mothers and babies. Even if a woman's husband is willing to do so, he may need much instruction and encouragement to provide even minimal care for his wife and baby.
d. Women are routinely taught that the ideal time to initiate breastfeeding is within the first hour after birth. During this time the baby is usually in the quiet alert state. However, women from cultures that wait hours or days to initiate breastfeeding are able to do so successfully.

3. What implications and priorities for nursing care can be drawn at this time?

The priority for nursing care at this time is to assist Mingyu in recovering from childbirth in a way that is congruent with her cultural beliefs. Every effort should be made to determine Mingyu's preferences with regard to diet, activity, and hygiene, and to honor them as much as possible. Although Mingyu's beliefs may seem unusual, they should be encouraged as long as she wants to conform to them and she and the baby suffer no ill effects. Culturally appropriate accommodations that can be made for Mingyu on the postpartum unit include providing a sponge bath if desired, offering only warm food and drink, and encouraging family members or friends to bring in especially desired foods if the hospital's dietary department is unable to provide them. If Mingyu desires, family members or friends can be encouraged to stay with her as much as possible to assist with her care and the baby's care.

Breastfeeding will also need to be addressed with Mingyu. A good way to determine the information Mingyu needs is to discover why she prefers to feed her baby infant formula. Discussing the benefits of colostrum for newborns may cause Mingyu to change her mind about delaying breastfeeding. Asian women may decide to breastfeed and offer formula as a supplement after breastfeeding. It is helpful for the nurse or lactation consultant to observe a breastfeeding session to identify any potential issues.

4. Does the evidence objectively support your conclusion?

There is a significant amount of information available concerning culturally appropriate care during the postpartum period for Asian women. Women who receive culturally appropriate care during this time will likely be more satisfied with their care. They will also be better able to assume care for themselves and their babies in the future if their early needs for passive nurturing are met.

5. Do alternative perspectives to your conclusion exist?

Not all women belonging to a particular cultural group will desire to use the traditional health practices that represent that group. Many young women who are first- or second-generation Americans follow their cultural traditions only when older family members are present or not at all. Adherents to the "melting pot" theory of acculturation in the United States would assert that women, regardless of their cultural heritage, should "act like Americans" if they live in America.

Critical Thinking/Clinical Decision Making
Weight Loss after Birth

Wendy, a primipara, is postpartum 3 days after giving birth by cesarean to a 9-pound son. She has had an uncomplicated recovery thus far, and breastfeeding is going well. During a discharge teaching session, Wendy expresses concern to the nurse about regaining her figure after childbirth and states that she is worried that she cannot fit into her business clothes when she returns to her job as an administrative assistant in 6 weeks. Before pregnancy, her weight was appropriate for her height. However, during pregnancy, she gained 46 pounds.

...

1. Evidence—Is evidence sufficient to draw conclusions about counseling women with regard to regaining their nonpregnant appearance?

Yes. Normal weight gain during pregnancy is approximately 25 pounds. Because Wendy gained almost twice that much weight during her pregnancy, she will need to make changes in her diet and exercise regularly in order to reach her prepregnant weight. There are multiple sources of information about diet and exercise during the postpartum period, including health care professionals, dietitians, web sites, television programs, and magazines available to Wendy. Although making changes in her diet and exercise regimen will not be easy, with determination and persistence Wendy can certainly succeed at regaining her prepregnant appearance.

2. Assumptions—What assumptions can be made about the following issues?
a. Appropriate diet for the postpartum mother who wants to improve her appearance
b. The relationship between breastfeeding and postpartum weight loss
c. Exercises for the postpartum woman who wants to improve her appearance
d. The relationship between perceived body image and self-esteem in postpartum women

Assumptions.
a. The postpartum woman will lose weight gradually if she consumes a balanced diet that provides slightly fewer calories than her daily energy expenditure. Most women rapidly lose several pounds during the month after birth. Because fat is the most concentrated source of calories in the diet, the first step in weight reduction is to identify sources of fat in the diet and explore ways to reduce them.
b. In general, the breastfeeding mother should eat a healthy, well-balanced diet that includes an extra 200 to 500 calories per day over nonpregnant requirements. According to the Institute of Medicine (IOM) (2005), the estimated energy requirement (EER) for a lactating woman during the first 6 months is 2700 kcal/day; during the next 6 months, the EER is 2768 kcal/day. Even with the increased caloric intake, women who are breastfeeding tend to lose weight more quickly than those who are formula feeding (Becker & Scott, 2008). Rapid weight reduction while breastfeeding may result in decreased milk supply; it is best to lose weight gradually while consuming a nutritious, well-balanced diet.
c. Women can begin exercising soon after birth, although they are encouraged to begin with simple exercises and gradually progress to more strenuous ones. Because Wendy has had a cesarean birth, she should not be doing any strenuous exercise for at least 4 to 6 weeks and has been cleared by her health care provider. The nurse might recommend walking as a beneficial form of exercise for Wendy during the next few weeks.
d. A woman's self-esteem is often related to her perceived body image. How a new mother feels about herself and her body may affect her behavior and adaptation to parenting.

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