Friday, November 19, 2010

Maternal and Child Health Nursing Chapter 11

Chapter 11
Promoting Fetal and Maternal Health

The health of a fetus and the health of the mother are inextricably linked. Generally, a woman who eats well and takes care of her own health during pregnancy provides a healthy environment for fetal growth and development. However, she may need instructions on exactly what constitutes a healthy lifestyle for herself and her baby. Most women have questions regarding how much extra rest they need, what type of exercise they can continue, and whether all the changes going on in their bodies, some of which bring them daily discomfort, are normal. Therefore, a major role in promoting maternal and fetal health is education. Providing empathetic advice about ways to alleviate the minor discomforts of pregnancy, alerting a woman to the danger signs of pregnancy, and keeping abreast of the latest evidence-based practice studies done on maternal exposure to teratogens (factors detrimental to fetal health) are all part of this role. National Health Goals have been established to increase the number of women receiving prenatal care (Box 11.1).
Health Promotion During Pregnancy
Health promotion during pregnancy begins with reviewing self-care.
Self-Care Needs
Because pregnancy is not an illness, few special care measures other than common sense about self-care are required. Many women, however, have heard different warnings about what they should or should not do during pregnancy, so the average woman needs some help separating fact from fiction so that she can enjoy her pregnancy unhampered by unnecessary restrictions. Be alert to the common misunderstandings of pregnancy. In no other area of nursing, except possibly for infant feeding, does there seem to be as many misconceptions or inappropriate information available to women.
At one time, tub baths were restricted during pregnancy because it was feared that bath water would enter the vagina and cervix and contaminate the uterine contents. Further, it was believed that hot water touching the abdomen might initiate labor. Because the vagina normally is in a closed position, however, the danger of tub bath water entering the cervix is minimal. In addition, water temperature has no documented effect on initiating labor. During pregnancy, sweating tends to increase because a woman excretes waste products for herself and a fetus. She also has an increase in vaginal discharge. For these reasons, daily tub baths or showers are now recommended.
As pregnancy advances, a woman may have difficulty maintaining her balance when getting in and out of a bathtub. If so, she should change to showering or sponge bathing for her own safety. If membranes rupture or vaginal bleeding is present, tub baths are contraindicated because then there might be a danger of contamination of uterine contents. During the last month of pregnancy, when the cervix may begin to dilate, some health care providers restrict tub bathing for the same reason.
Breast Care
A few precautions during pregnancy are helpful to prevent breast discomfort. A general rule is for a woman to wear a firm, supportive bra with wide straps to spread weight across the shoulders. A woman may need to buy a larger bra halfway through pregnancy to accommodate increased breast size. If she plans on breast-feeding her newborn, she might choose to buy bras suitable for breast-feeding so she can continue to use them after the baby's birth.
At about the 16th week of pregnancy, colostrum secretion begins in the breasts. The sensation of a fluid discharge from the breasts can be frightening unless a woman is warned that this is a possibility. Instruct her to wash her breasts with clear tap water (no soap, because that could be drying) daily to remove the colostrum and reduce the risk of infection. Afterward, she should dry her nipples well by patting them.
If colostrum secretion is profuse, a woman may need to place gauze squares or breast pads inside her bra, changing them frequently to maintain dryness. Otherwise, constant moisture next to the breast nipple can cause nipple excoriation, pain, and fissuring.
Dental Care
Gingival tissue tends to hypertrophy during pregnancy. Unless a pregnant woman brushes well, pockets of plaque form readily between the enlarged gumline and teeth. In addition, encourage pregnant women to see their dentists regularly for routine examination and cleaning. Nine months is a fairly long time to be without preventive dental care. Although a pregnant woman should question the need for x-rays during pregnancy, if these are necessary for dental health, they can be done safely as long as a woman's abdomen is shielded with a lead apron.
Tooth decay occurs from the action of bacteria on sugar. This action lowers the pH of the mouth, creating an acid medium that leads to etching or destruction of the enamel of teeth. Encourage the woman to snack on nutritious foods, such as fresh fruits and vegetables like apples and carrots to avoid sugar coming in contact with the teeth. If a client has trouble avoiding sweet snacks such as candy, suggest eating sweet snacks that dissolve easily (like a chocolate bar) rather than those that remain in the mouth a long time (like chewy candy). This helps to minimize the level of sugar in the mouth.

Perineal Hygiene
Although women have increased vaginal discharge during pregnancy, douching is contraindicated because the force of the irrigating fluid could cause it to enter the cervix and lead to infection. In addition, douching alters the pH of the vagina, leading to an increased risk of bacterial growth.
The days when a woman had to purchase a completely new maternity wardrobe have disappeared. Although economically advantageous, this may be disappointing to a woman who wants to announce her pregnancy early by wearing maternity clothing.
A woman should avoid garters, extremely firm girdles with panty legs, and knee-high stockings because these may impede lower-extremity circulation. Suggest wearing shoes with a moderate to low heel to minimize pelvic tilt and possible backache. Otherwise, the rules are common sense and comfort.
Sexual Activity
Some women are embarrassed to ask questions about sexual relations during pregnancy. However, most women are concerned about whether sexual intercourse should be restricted. Many need information to refute some of the myths about sexual relations in pregnancy that still exist, such as:
  • Coitus on the expected date of her period will initiate labor.
  • Orgasm will initiate labor, but participating in sexual relations without orgasm will not.
  • Coitus during the fertile days of a cycle will cause a second pregnancy or twins.
  • Coitus might cause rupture of the membranes.
None of these is true. Asking a woman at a prenatal visit if she has any questions about sexual activity allows her to voice such concerns (Box 11.4). Then you can help dispel these myths, allowing a woman to feel more comfortable and secure that coitus is not harming her child.
Women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of the pregnancy when a previous miscarriage occurred. Women whose membranes have ruptured or who have vaginal spotting should be advised against coitus until examined to prevent possible infection (Read, 2004). Advise caution about male oral–female genital contact, because accidental air embolism has been reported from this act during pregnancy (Katz, 2003). Otherwise, there are no sexual restrictions during pregnancy.
Early in pregnancy, a woman may experience a decreased desire for coitus resulting from the increased estrogen level in her body. Breast tenderness may limit a usual pattern of sexual arousal. As pelvic congestion increases from the additional uterine blood supply, most women notice increased clitoral sensation. Some women may experience orgasm for the first time during pregnancy because of the increased pelvic congestion. As pregnancy advances and a woman's abdomen increases in size, she and her sexual partner may need to use new positions for intercourse. A side-by-side position or a woman in a superior position may be more comfortable. As vaginal secretions change, a woman may find a water-soluble lubricant helpful. If she begins to experience discomfort from penile penetration, mutual masturbation or female oral–male genital relations might be satisfying to both partners. Caution women with a non-monogamous sexual partner that the partner needs to use a condom to prevent transmission of a sexually transmitted infection during pregnancy. Women may use female condoms throughout pregnancy.

Exercise during pregnancy is important to prevent circulatory stasis in the lower extremities. It also can offer a general feeling of well-being (Kramer, 2005). For some women, teaching about exercise focuses on helping them realize the need for exercise and urging them to get enough. Others may need to be cautioned to restrict exercise or participation in contact sports.
Extreme exercise has been associated with a lower birth rate. The American College of Obstetricians and Gynecologists (ACOG) recommends that the average, well-nourished women should exercise during pregnancy every day for 30 consecutive minutes (ACOG, 2002). An exercise program should consist of 5 minutes of warm-up exercises, an active “stimulus” phase of 20 minutes, and then 5 minutes of cool-down exercises. The type of activity chosen depends on a woman's interests. Exercises that exercise large muscle groups rhythmically, such as walking, are best. The intensity of the exercise program depends on a woman's cardiopulmonary fitness. Before she begins any exercise program, make sure a woman has consulted her physician or nurse-midwife. If any complication of pregnancy should occur, such as bleeding or pregnancy-induced hypertension (PIH), a woman should discontinue her exercise program until she rechecks with her primary health care provider about continuing the program.
Both pregnant and nonpregnant women should exercise at 70% to 85% of their maximum heart rate. The easiest way to calculate this is to subtract a woman's age from 220, then multiply this by 70% or 85%. For example, after exercise a 23-year-old woman should have a pulse range of 137 to 167 (220 minus 23 times 70% and 85%). For a woman of 35, this target range would be 129 to 157.
Teach the client how to assess quickly if she is exercising too strenuously by evaluating her ability to continue talking while exercising. If she is too short of breath to do this, she is exercising beyond her target heart rate.
A planned exercise program may have long-term benefits such as:
  • Lowered cholesterol level
  • Reduced risk of osteoporosis
  • Increased energy level
  • Maintenance of healthy body weight
  • Decreased risk of heart disease
  • Increased self-esteem and well-being
As a rule, a woman can continue any sport she participated in before pregnancy unless it was one that involved body contact, such as soccer. If a woman is a competent horsewoman, for example, there is little reason for her to discontinue riding until it becomes uncomfortable. Pregnancy is not the time to learn to ride, however, because a beginning rider is at greater risk for being thrown than an experienced one. The same principles apply to skiing and bicycling. An accomplished skier or bicyclist may continue the activity in moderation until balance becomes a problem. Pregnancy is not the time to learn to ski or ride a bicycle, however, because the lack of skill may result in many falls.
Swimming is a good activity for pregnant women and, like bathing, is not contraindicated as long as the membranes are intact. It may help relieve backache during pregnancy (Young & Jewell, 2005). Long-distance swimming or any other activity carried out to a point of extreme fatigue should be avoided. A high-impact aerobics program is contraindicated because this can be strenuous to both pelvic and knee joints. In addition, it may lead to hyperthermia for the mother and fetus. Epidemiologic studies suggest that an elevation of maternal body temperature by 2 degrees C for at least 24 hours can cause a range of developmental defects, but there is little information on thresholds for shorter exposures (Edwards, Saunders, & Shiota, 2003). Use of hot tubs and saunas after workouts longer than 15 minutes is contraindicated, however, on the chance these could raise the internal fetal temperature.
Walking is the best exercise during pregnancy, and women should be encouraged to take a walk daily unless inclement weather, many levels of stairs, or an unsafe neighborhood are contraindications. Jogging, in contrast, is questioned because of the strain that the extra weight of pregnancy places on the knees. Late in pregnancy, jogging can cause pelvic pain from relaxed symphysis pubis movement. Guidelines for exercise during pregnancy are highlighted in Box 11.5.
The optimal condition for body growth occurs when growth hormone secretion is at its highest level—that is, during sleep. This, plus the overall increased metabolic demand of pregnancy, appears to be the physiologic reason pregnant women need an increased amount of sleep or at least rest to build new body cells during pregnancy.
Pregnant women rarely have difficulty falling asleep at night because of this increased physiologic need for sleep. If a woman has trouble falling asleep, drinking a glass of warm milk may help. Relaxation exercises (lying quietly, systematically relaxing neck muscles, shoulder muscles, arm muscles, and so on) also may be effective.
Late in pregnancy, a woman often finds herself awakened from sleep at short, frequent intervals by the activity of her fetus. Frequent waking this way leads to loss of REM (rapid eye movement) sleep. On arising, a woman may feel anxious or not well rested, although she has slept her usual number of hours. She also may awaken with pyrosis or dyspnea if she has been lying flat. In this instance, sleeping on two pillows or on a couch with an armrest may be helpful.
To obtain enough sleep and rest during pregnancy, most pregnant women need a rest period during the afternoon as well as a full night of sleep. A good resting or sleeping position is a modified Sims' position, with the top leg forward (Fig. 11.1). This puts the weight of the fetus on the bed, not on the woman, and allows good circulation in the lower extremities.
Be certain the client knows to avoid resting in a supine position, as supine hypotension syndrome (faintness, diaphoresis, and hypotension from the pressure of the expanding uterus on the inferior vena cava) can develop in this position. Also be certain she knows not to rest with her knees sharply bent either when sitting or lying down, because of the increased risk of venous stasis this causes below the knee.

Unless a woman's job involves exposure to toxic substances, lifting heavy objects, other kinds of excessive physical strain, long periods of standing, or having to maintain body balance, there are few reasons a woman cannot continue to work throughout pregnancy (Saurel-Cubizolles et al., 2004). Changes in public assistance laws that encourage women to seek employment have led to more women working during pregnancy than ever before. To protect women from loss of employment benefits during pregnancy, Congress passed an employment rights law in 1978 (Public Law 95-555). However, this law does not cover women who work for companies with fewer than 15 employees.
FIGURE 11.1 A modified Sims' position is a good rest position during pregnancy. Notice that the weight of the fetus rests on the bed.
According to this law, an employer cannot:
  • Deprive women of seniority rights, in pay or promotion, because they take a maternity leave
  • Treat women returning from maternity leave as new hires, starting over on the eligibility period for pension and other benefits
  • Force pregnant women to leave if they are able to and want to continue working
  • Refuse to hire women just because they are pregnant or fire them for the same reason
  • Refuse to cover employees' normal pregnancy and delivery expenses in the company health plan or pay less for pregnancy than for other medical conditions
  • Refuse to pay sick leave or disability benefits to women whose difficult pregnancies keep them off the job
Passed in 1993, the Family Leave Act, another federal law, guarantees women the right to 12 weeks of unpaid, job-protected leave on the birth of a child, the adoption or foster placement of a child, when a woman is needed to care for a parent, spouse, or child with a serious health condition, or because of a serious health condition in herself (29 CFR 825.11). Specifically mentioned in the law is any period of incapacity due to pregnancy or for prenatal care (American Public Health Association, 2001). Families need to be educated about this important law because

many women are still not aware that they can take time off from work during pregnancy or spend time with a new baby. Additional women may be able to qualify for provisions under the Americans With Disabilities Act.
Some occupations are hazardous during pregnancy because they bring women into contact with harmful substances. For example, nurses working with anesthetic gases in operating rooms or dental offices are reported to have a higher incidence of spontaneous miscarriage and, possibly, congenital anomalies in children than nurses working in other locales, probably due to exposure to nitrous oxide (National Institute of Occupational Safety and Health, 2000). This finding suggests that breathing even a low dose of anesthetic gases such as nitrous oxide can be a serious occupational hazard for nurses. Nurses working with chemotherapy agents should wear gloves to protect themselves from exposure to these drugs, which are possibly teratogenic. Ribavirin (Virazole), an antibiotic used to treat respiratory syncytial infections, is also apparently teratogenic if inhaled by health care providers (Karch, 2004).
A number of studies suggest that preterm birth may occur more frequently in women who work at strenuous jobs or those that require long periods of standing (Saurel-Cubizolles et al., 2004). Other problems that can occur with employment include interference with adequate rest and nutrition. Urge a woman who works outside her home to put her feet up to rest when performing tasks that can be done in that position. Review what she eats at fast-food restaurants or packs for herself to be certain she plans ways to make this type of lunch as nutritious as if she were eating at home.
Remember, most women work to augment or supply the family income, not for fun. Even those who could afford to leave their jobs may not be willing to sacrifice the collegial relationships and sense of fulfillment derived from work, or the lifestyle their income has allowed them to enjoy. Counseling them to reserve periods during the day for rest and to eat a healthy diet is more effective than suggesting they resign from their jobs during pregnancy to get more rest (Box 11.6).
Many women have questions about travel during pregnancy (Kingman & Economides, 2003). Early in a normal pregnancy, there are no restrictions. If a woman is susceptible to motion sickness, she should not take any medication for this unless it is specifically prescribed or approved by her physician or nurse-midwife. Late in pregnancy, travel plans should take into consideration the possibility of early labor, requiring birth at a strange setting where a woman's obstetric history will be unknown.
Regardless of the month of her pregnancy, if a woman plans to spend time at a remote location, such as a campsite, be certain she knows the location of a nearby health care facility should an unexpected complication occur. Caution her not to eat uncooked fruits, vegetables, and meat or drink unpurified water. If she is going to be away from home for an extended time, she needs to make arrangements to visit a health care provider in that area so she can keep the schedule of her regular prenatal visits. Encourage her to make these plans far enough in advance so that her records can be copied and sent with her or be forwarded to the interim health care provider. Be aware that you need her written permission to send records. Also, make sure she has enough of her prescribed

vitamin supplement plus adequate prescriptions for refills as necessary.
Advise a woman who is taking a long trip by automobile to plan for frequent rest or stretch periods. Preferably every hour, but at least every 2 hours, she should get out of the car and walk a short distance. This break will relieve stiffness and muscle ache and improve lower extremity circulation, helping to prevent varicosities, hemorrhoids, and thrombophlebitis.
Pregnant women may drive as long as they fit comfortably behind the steering wheel. They should use seat belts like everyone else (Box 11.7). Occasionally, uterine rupture has been reported from seat belt use, but overall evidence suggests that seat belts reduce mortality among pregnant women in car accidents, as they do for everyone. Both shoulder harnesses and lap belts should be used. The lap belt should be worn as snugly as comfortable so that it fits under the abdominal bulge and across the pelvic bones. The shoulder harness should be snug but comfortable, worn across the shoulder, chest, and upper abdomen. A pad may be placed under the shoulder harness at the neck to avoid chafing (Fig. 11.2).
Pregnancy is also a time for a family to think about transportation safety for the newborn. Purchasing a car seat is an investment that not only is legally required for transporting infants but also helps guarantee their safety. Families who cannot afford to purchase an infant car seat may want to ask friends or relatives about the possibility of borrowing one no longer needed. Many hospitals and local Red Cross chapters provide infant seats on a rental or loan basis for families who may find it difficult to obtain one in other ways.
FIGURE 11.2 Encourage women to wear seatbelts during pregnancy. The bottom strap should cross beneath the abdomen.
Traveling by plane is not contraindicated as long as the plane has a well-pressurized cabin (true of commercial airlines but not of all small private planes). Some airlines do not permit women who are more than 7 months pregnant on board; others require written permission from a woman's primary care provider. Advise a woman to investigate these restrictions by calling the airline or a travel agency before making travel plans.
With businesses becoming global, more women than ever before are asked to travel internationally. Women who travel abroad may need additional immunizations, such as cholera vaccine, for entry into certain countries (Schmidt, Kroger, & Roy, 2004). All live virus vaccines (measles, mumps, rubella, and yellow fever) are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy. Before any immunization during pregnancy, the woman should ask her primary care provider to verify it will be safe. Pregnancy does not alter indications for rabies vaccine because without the vaccine, a fatal disease could occur. Tetanus is also treated the same in pregnant women as in others (Sheffield & Ramin, 2004).

Discomforts of Early Pregnancy: The First Trimester
Although most women are pleased to be pregnant, the symptoms of early pregnancy tend to cause discomfort to a woman rather than provide evidence that she is carrying a child. As such, a woman may become frustrated, expecting pregnancy to be a time of glowing good health. Providing empathetic and sound advice about measures to relieve these discomforts helps promote overall health and well-being. Although the symptoms discussed below are classified as minor, they may not seem minor to a woman who wakes up each morning feeling nauseated, wondering if she will ever feel like herself again. Also, each of these symptoms has the potential to lead to problems that are more serious.
Nursing Diagnoses
Listening, observing carefully, and developing nursing diagnoses based on assessment data are important steps in prenatal care. Keep in mind that although many women will experience one or several of these symptoms, each woman's experience is unique and nursing diagnoses must be developed according to each woman's individual needs. Examples of nursing diagnoses that might be developed for women experiencing the discomforts of early pregnancy are:
  • Health-seeking behaviors related to interest in using herbal remedies to relieve discomforts of pregnancy
  • Disturbed body image related to breast and abdominal enlargement in pregnancy
  • Constipation related to reduced peristalsis in pregnancy
  • Fatigue related to increased physiologic need for sleep and rest during pregnancy
  • Acute pain related to frequent muscle cramps secondary to physiologic changes of pregnancy
  • Disturbed sleep pattern related to frequent need to empty bladder during night
Breast Tenderness
Breast tenderness is often one of the first symptoms noticed in early pregnancy; it may be most noticeable on exposure to cold air. For most women, the tenderness is minimal and transient, something they are aware of but not something that overly concerns them. If the tenderness is enough to cause discomfort, encourage a woman to wear a bra with a wide shoulder strap for support and to dress warmly to avoid cold drafts if cold increases symptoms. If actual pain exists, the presence of conditions such as nipple fissure or other explanations for the pain, such as breast abscess, should be ruled out.
Palmar Erythema
Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused by increased estrogen levels. Constant redness or itching of the palms may make a woman believe she has developed an allergy. Explain that this type of itching in early pregnancy is normal before she spends time and effort trying different soaps or detergents or attempting to implicate certain foods she has eaten. For some women, calamine lotion is soothing. As soon as her body adjusts to the increased level of estrogen, the erythema and pruritus disappear.
As the weight of the growing uterus presses against the bowel and peristalsis slows, constipation may occur (Wald, 2003). Discuss preventive measures with a woman early in pregnancy to help her avoid this problem. Encourage her to evacuate her bowels regularly (many women neglect this first simple rule); to increase the amount of roughage in her diet by eating raw fruits, bran, and vegetables; and to drink at least eight 8-oz glasses of water daily.
Some women find their prescribed oral iron supplement contributes to constipation. Reinforce the need for this supplement to build fetal iron stores. Help a woman find a method to relieve or prevent constipation other than not taking the supplement.
Advise a woman not to use mineral oil to relieve constipation, because it can absorb fat-soluble vitamins (A, D, K, and E), which are necessary for both good fetal and maternal health, and flush them out of the body.
Enemas also should be avoided because their action might initiate labor. Over-the-counter laxatives are contraindicated, as are all nonessential drugs during pregnancy unless specifically prescribed or sanctioned by a woman's physician or nurse-midwife (Yankowitz, 2003). If dietary measures and attempts at regular bowel evacuation fail, a stool softener, such as docusate sodium (Colace), or evacuation suppositories, such as glycerin, may be prescribed. Some women have extensive flatulence accompanying constipation. Recommend avoiding gas-forming foods, such as cabbage or beans, to help control this problem.
Nausea, Vomiting, and Pyrosis
At least half of pregnant women experience other gastrointestinal symptoms such as nausea, vomiting, and pyrosis. Because these symptoms also interfere with nutrition, they are discussed in Chapter 12.
Fatigue is extremely common in early pregnancy, probably due to increased metabolic requirements. Much of it can be relieved by increasing the amount of rest and sleep. Some women are reluctant to take time out of their day for rest. They know that pregnancy is not an illness, and so they proceed as if nothing

is happening to them. Rarely is there justification during a normal pregnancy for women to take extra days off from work because of their condition, but it is also unrealistic to proceed as if nothing is happening. Fatigue can increase the amount of morning sickness a woman experiences. If she becomes too tired, she may not eat properly and nutrition can suffer. If she remains on her feet without at least one break during the day, the risk for varicosities and the danger of thromboembolic complications increase.
For all these reasons, ask women at prenatal visits whether they manage to have at least one short rest period every day. A good resting position is a modified Sims' position, with the top leg forward (see Fig. 11.1). This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in the lower extremities.
A woman who works outside her home at a job that requires her to be on her feet most of the day might use part of her lunch hour to sit with her feet elevated, such as on an adjoining chair (Fig. 11.3). After she returns home from work in the evening, she may need to modify her customary routine from typical activities such as cooking dinner or watching a child's soccer game to resting, then cooking dinner or going to the soccer game, or resting while her partner cooks dinner (part of “we are having a baby at our house” for a partner who does not usually share in household chores). Women who work at sedentary jobs, inside or outside their home, may, in contrast, need to use this time to increase their activity, such as taking a walk or using a treadmill.
Muscle Cramps
Decreased serum calcium levels, increased serum phosphorus levels, and, possibly, interference with circulation commonly cause muscle cramps of the lower extremities during pregnancy. These problems are best relieved if a woman lies on her back momentarily and extends her involved leg while keeping her knee straight and dorsiflexing the foot until the pain disappears (Fig. 11.4).
If a woman is experiencing frequent leg cramps, she may need a prescription for aluminum hydroxide gel (Amphojel), which binds phosphorus in the intestinal tract and thereby lowers its circulating level. Lowering milk intake to only a pint daily and supplementing this with calcium lactate may also help to reduce the phosphorus level. Elevating lower extremities frequently during the day to improve circulation and avoiding full leg extension, such as stretching with the toes pointed, may be helpful prevention. Typically, muscle cramps are a minor symptom of pregnancy, but the pain is extreme and the intensity of the contraction can be frightening. Always ask at prenatal visits if this is a problem. Otherwise, women may not realize that cramping is pregnancy-related and so fail to report it.
FIGURE 11.3 A “feet-up” break during a workday helps prevent ankle edema. (© Caroline Brown, RNC, MS, DEd.)
FIGURE 11.4 Relieving a leg cramp in pregnancy. Pressing down on the knee and pressing the toes backward (dorsiflexion) relieves most cramps. Here, a woman's partner helps.
Pregnant women also have a higher incidence of “restless leg syndrome” (waking at night because of spontaneous leg movement) than nonpregnant women (Manconi et al., 2004). This movement can be so annoying and frequent that women have difficulty sleeping.
Supine hypotension is a symptom that occurs when a woman lies on her back and the uterus presses on the vena cava, impairing blood return to her heart. A woman experiences an irregular heart rate and a feeling of apprehension. To relieve the problem is simple: if a woman turns or is turned onto her side, pressure will be removed from the vena cava, blood flow will be restored, and the symptoms will quickly fade.
If a woman rises suddenly from a lying or sitting position or stands for an extended time in a warm or crowded area, she may faint from the same phenomenon (blood pooling in the pelvic area or lower extremities). Rising slowly and avoiding extended periods of standing prevent this problem. If a woman should feel faint, sitting with her head lowered—the same action as for any person who feels faint—will alleviate the problem.
Varicosities, or the development of tortuous leg veins, are common in pregnancy because the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities (Katz, 2003). This causes pooling of blood and distention of the vessels. The veins become engorged, inflamed, and painful. Although usually confined to the lower extremities, varicosities can extend up to and include the vulva. They occur most frequently

in women with a family history of varicose veins and those who have a large fetus or a multiple pregnancy. Urge such women to take active measures to prevent varicosities beginning in early pregnancy; if left until the second trimester, the best they will be able to accomplish is relief of pain from already formed varicosities.
Resting in a Sims' position or on the back with the legs raised against the wall or elevated on a footstool for 15 to 20 minutes twice a day is a good precaution (Fig. 11.5). Caution women not to sit with their legs crossed or their knees bent and to avoid constrictive knee-high hose or garters.
Some women, especially those who developed varicosities during a previous pregnancy, may need elastic support stockings such as TEDS for relief of varicosities. A woman should don the support stockings before she arises in the morning. Once she is on her feet, the pooling of blood has already begun, and the stockings will be less effective. When applied properly, the stockings should reach an area above the point of distention. Before a woman buys stockings, be certain she understands that the stockings should be labeled “medical support hose.” Many pantyhose manufacturers advertise their stockings as giving “firm support,” and a woman may assume erroneously this is sufficient for her.
Because it stimulates venous return, exercise is as effective as rest periods at alleviating varicosities. Most women assume they do not need set exercise periods during pregnancy because they work hard at other activities. If they analyze the type of work they do, however, they may realize that a great deal of their work leads to venous stasis of the lower extremities. Women stand in one position to wash dishes, cook dinner, run a copying machine, defend a client in court, process a part on an assembly line, or teach a class. Sitting at a desk for prolonged periods of time with legs dependent also encourages venous stasis. Advise women to break up these long periods of sitting or standing with a “walk break” at least twice a day. As a rule, their families will benefit by accompanying them. Partners may discover that they, too, walk very little during their workday.
Vitamin C may be helpful in reducing the size of varicosities because it is necessary for the formation of blood vessel collagen and endothelium. Ask at prenatal visits if women include fresh fruit in their diet every day.
FIGURE 11.5 Position to relieve varicosities. The mother keeps a pad under her right hip to prevent supine hypotensive syndrome.
Hemorrhoids (varicosities of the rectal veins) occur commonly in pregnancy because of pressure on these veins from the bulk of the growing uterus. Daily bowel evacuation to relieve constipation and resting in a modified Sims' position daily are both helpful. At day's end, assuming a knee–chest position (Fig. 11.6) for 10 to 15 minutes is an excellent way to reduce the pressure on rectal veins. Keep in mind that a knee–chest position may make a woman feel lightheaded initially. Therefore, instruct her to remain in this position for only a few minutes at first, and then gradually increase the time until she can maintain the position comfortably for about 15 minutes. Stool softeners may be recommended for a woman who already has hemorrhoids. Applying witch hazel or cold compresses to external hemorrhoids may help to relieve pain. Replacing hemorrhoids with gentle finger pressure can be helpful. As with varicosities, think prevention, not just providing help for already established hemorrhoids.
Heart Palpitations
On sudden movement, such as turning over in bed, a pregnant woman may experience a bounding palpitation of the heart. This is probably due to the circulatory adjustments necessary to accommodate her increased blood supply during

pregnancy. Although only momentary, the sensation can be frightening because the heart seems to have skipped a beat. It is reassuring for women to know that palpitations are normal and to be expected on occasion. Only if they occur very frequently or continuously or are accompanied by pain are they a concern. Gradual, slow movements will help prevent this from happening so frequently.
FIGURE 11.6 Knee–chest position. Because the weight of the uterus is shifted forward, this position promotes free flow of urine from the kidneys (preventing urinary tract stasis and infection) and better circulation in the rectal area (preventing hemorrhoids).
Frequent Urination
Frequent urination occurs in early pregnancy due to the pressure of the growing uterus on the anterior bladder. The sensation may last for about 3 months, sometimes beginning as early as the first or second missed menstrual period, disappear in midpregnancy when the uterus rises above the bladder, and return again in late pregnancy as the fetal head presses against the bladder (Fig. 11.7).
When a woman describes frequency of urination, be certain this is the only urinary symptom she is experiencing. Ask her about any burning or pain on urination or whether she has noticed any blood in her urine, signs of urinary tract infection.
There are no solutions for decreasing the frequency of urination. Women should not restrict their fluid intake, as fluids are necessary to allow their blood volume to double. Suggesting that a woman reduce the amount of caffeine she is drinking may be helpful. Most importantly, a woman needs to understand that voiding more frequently is a normal phenomenon. Unless a woman is cautioned that the sensation of frequency returns after lightening (the settling of the fetal head into the inlet of the pelvis at pregnancy's end), she may worry at that time that she has a urinary tract infection. Again, unless other symptoms are present, she can be assured this a normal finding.
Occasionally, a woman notices stress incontinence (involuntary loss of urine on coughing or sneezing) during pregnancy. Although this is largely unpreventable, doing Kegel exercises (alternately contracting and relaxing perineal muscles; Box 11.8) helps strengthen urinary control, directly strengthens perineal muscles for birth, and decreases the possibility of stress incontinence (Harvey, 2003).
FIGURE 11.7 Bladder changes during pregnancy. (A) Early pregnancy: the uterus presses against the bladder, causing frequent urination. (B) Middle pregnancy: urinary frequency is relieved. (C) Late pregnancy: the uterus is again pressing on the bladder, leading to the recurrence of urinary frequency.
Abdominal Discomfort
Some women experience uncomfortable feelings of abdominal pressure early in pregnancy. Women with a multiple pregnancy may notice this throughout pregnancy. Typically, pregnant women stand with their arms crossed in front of them because the weight of their arms resting on their abdomen relieves this discomfort.

When women stand up quickly, they may experience a pulling, sometimes sharp and frightening, pain in the right or left lower abdomen from tension on a round ligament. They can prevent this by always rising slowly from a lying to a sitting, or from a sitting to a standing position. Because round ligament pain may simulate the abrupt pain that occurs with ruptured ectopic pregnancy, the client's description of the pain must be evaluated carefully (Katz, 2003).
Leukorrhea, a whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen levels and the increased blood supply to the vaginal epithelium and cervix in pregnancy. A daily bath or shower to wash away accumulated secretions and prevent vulvar excoriation usually controls this problem. Wearing cotton underpants and sleeping at night without underwear can be helpful to reduce moisture and possible vulvar excoriation. Some women may need to wear a perineal pad to control the discharge. Caution women not to use tampons because this could lead to stasis of secretions and subsequent infection. Advise women to contact their physician or nurse-midwife if there is a change in the color, odor, or character of this discharge, which might suggest infection. Caution women not to douche; douching is contraindicated throughout pregnancy because fluid could be forced into the uterine cervix.
A woman with vulvar pruritus needs evaluation because this strongly indicates infection. Be certain she is describing pruritus-like symptoms and is not describing burning on urination, a sign of an early bladder infection (which also needs therapy, but of a different type). Common vaginal infections such as Candida that present with pruritus are discussed in Chapter 47.
Avoiding tight underpants and pantyhose may help prevent vulvar and vaginal infections, particularly yeast infections. Although over-the-counter medications for yeast infections are available, caution women to contact their health care provider rather than self-treat vaginal infections during pregnancy so their health care provider knows infections are occurring.
A woman who is uncomfortable about discussing this part of her body or who associates vaginal infections with poor hygiene or sexually transmitted infection may be reluctant to mention an irritating vaginal discharge. Therefore, at each prenatal visit, be sure to ask the woman specifically whether she is experiencing this problem.
Discomforts of Middle to Late Pregnancy
At approximately the 20th to 24th weeks, the midpoint of pregnancy, a woman is usually ready for further health teaching that relates to the new developments that will occur in the latter half of pregnancy. As she starts to view the child within her as a separate person, she becomes interested in discussing and making plans for the signs and symptoms of beginning labor, birth, and the infant's care. The midpoint of a pregnancy also is a good time to describe the new minor symptoms that may occur and to review the precautionary measures to prevent constipation, varicosities, and hemorrhoids, as these increase in intensity late in pregnancy.
Nursing Diagnoses
Examples of possible nursing diagnoses associated with the discomforts of middle to late pregnancy are:
  • Health-seeking behaviors related to discomforts of middle to late pregnancy
  • Acute pain related to sudden postural change in pregnancy
  • Anxiety related to shortness of breath resulting from expanding uterine pressure on diaphragm
  • Deficient knowledge related to occurrence of Braxton Hicks contractions in late pregnancy
Box 11.9 highlights appropriate outcomes and interventions related to monitoring the mother in the later part of pregnancy, using the terminology identified by the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC).
As pregnancy advances, a lumbar lordosis occurs and postural changes necessary to maintain balance may lead to backache. Wearing shoes with low to moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. Encouraging a woman to walk with her pelvis tilted forward (putting pelvic support under the weight of the fetus) is also helpful. In addition, applying local heat may aid in relieving backache.
To avoid back strain, advise women to squat rather than bend over to pick up objects. Also encourage them always to lift objects by holding them close to the body. For some women, a firmer mattress during this time may be required. Sliding a board under the mattress is a cost-effective alternative for achieving a firmer sleeping surface. Pelvic rocking or tilting, an exercise described in Chapter 13, also helps to prevent and relieve backache.
Backache can be an initial sign of a bladder or kidney infection. Obtaining a detailed account of a woman's symptoms is crucial to ensure that she is describing only backache. Too often, women are observed at a prenatal visit only lying in a lithotomy position on an examining table. Always assess the manner in which a woman walks and what type of shoes she wears as she moves from a waiting room to an examining room to evaluate whether her posture or shoes could be a cause.
Caution women not to take herbal remedies, muscle relaxants, or analgesics (or any other medication) for back pain without first consulting their physician or nurse-midwife. Generally, acetaminophen (Tylenol) is considered to be safe and effective for relieving this type of pain during pregnancy.

Many women experience headache during pregnancy, apparently from their expanding blood volume, which puts pressure on cerebral arteries. Trying to reduce any possible causative situations, such as eye strain or tension, may lessen the number of headaches they experience. Resting with cold towels on their forehead and taking usual adult doses of acetaminophen usually furnish adequate relief. Although a few women who have migraine headaches find these worsen during pregnancy, most women notice considerable improvement with this type of headache (Gladstone, Eross, & Dodick, 2004) (see Chapter 49). Caution women that if a headache is unusually intense or continuous, they should report it to their primary care provider. This type of headache may be a danger sign of pregnancy caused by high blood pressure.
As the expanding uterus puts pressure on the diaphragm, it causes lung compression and shortness of breath. A woman will notice this primarily at night when her body is flat. She also will definitely notice it on exertion. To relieve nighttime dyspnea, advise her to sleep upright, allowing the weight of the uterus to fall away from her diaphragm. As pregnancy progresses, she may require two or more pillows to sleep on at night to avoid the problem. Caution her to limit her activities during the day to prevent exertional dyspnea. Always question women about this important symptom at prenatal visits to be certain the sensation is not continuous, which describes more than usual involvement.
Ankle Edema
Most women experience some swelling of the ankles and feet during late pregnancy, most noticeably at the end of the day. Women are often conscious of this first when they kick off their shoes and then cannot put them on again comfortably.
As long as proteinuria and hypertension are absent, ankle edema of this nature is a normal occurrence of pregnancy. It is probably caused by reduced blood circulation in the lower extremities due to uterine pressure and general fluid retention. This simple edema can be relieved best by resting in a left side-lying position because this increases the kidney's glomerular filtration rate and allows good venous return. Sitting for half an hour in the afternoon and again in the evening with the legs elevated is also helpful. Women should avoid wearing constricting clothing such as panty girdles or knee-high stockings because these impede lower extremity circulation and venous return.
Some women need reassurance that ankle edema is normal during pregnancy. Otherwise, they worry that it is a

beginning sign of pregnancy-induced hypertension (PIH). On the other hand, do not dismiss a report of lower extremity edema lightly until you are certain a woman does not exhibit any signs of proteinuria or edema of other, nondependent parts, or has had a sudden increase in weight indicative of PIH.
Braxton Hicks Contractions
Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. Early in pregnancy, these contractions, termed Braxton Hicks contractions, are not noticeable. By middle or late pregnancy, the contractions become stronger, and a woman who tenses at the sensation may even experience some minimal pain, similar to a hard menstrual cramp. Although these contractions are not a sign of beginning labor, women should telephone or e-mail their primary care provider to report them so that they can be evaluated. A rhythmic pattern of even very light contractions can be a beginning sign of labor.
Danger Signs of Pregnancy
Although most danger signs of pregnancy occur toward the end of pregnancy, women need to know about them from the beginning. To introduce these, assure a pregnant woman you have every reason to believe she is going to have a normal, uncomplicated pregnancy (assuming that is true) as well as no reason to think she is going to experience any serious problems, but if any of the things described below do occur, she should inform her health care provider by telephone or e-mail immediately. Be certain you give her an alternate contact number to call if the health care facility is closed. Emphasize that if one of these danger signs should occur, it serves merely as a signal of the possibility that something may happen, not that something serious has happened. It is important for her to report it immediately, though, so it can be dealt with before something harmful does occur.
Vaginal Bleeding
A woman should report vaginal bleeding, no matter how slight, because some of the serious bleeding complications of pregnancy begin with only slight spotting. When talking with a woman, ask her how she discovered the spotting. If she discovered it on toilet paper following a bowel movement, she's probably reporting spotting from hemorrhoids. Until the bleeding is found to be innocent, however, all women with spotting need further evaluation.
Persistent Vomiting
Once- or twice-daily vomiting is not uncommon during the first trimester of pregnancy. However, persistent, frequent vomiting is not normal. Vomiting that continues past the 12th week of pregnancy is also extended vomiting. Persistent or extended vomiting depletes the nutritional supply available to a fetus and is a danger to the pregnancy. (See Chapter 12 for a discussion of persistent vomiting [hyperemesis gravidarum].)
Chills and Fever
Chills and fever may indicate an intrauterine infection, a serious complication for both a woman and a fetus. These also may be symptoms of a relatively benign gastroenteritis. However, because a woman cannot make a definite determination about the cause, further evaluation by a health care provider is necessary.
Sudden Escape of Clear Fluid from the Vagina
When a gush of clear fluid is discharged suddenly from the vagina, it means the membranes have ruptured and mother and fetus are now both threatened, because the uterine cavity is no longer sealed against infection. If a fetus is small and the head does not fit snugly into the cervix, the umbilical cord may prolapse following membrane rupture. If the cord is then compressed by the fetal head, oxygenation is compromised and a fetus will be in immediate and grave danger. Alerting a health care provider to any sudden escape of fluid is crucial so a safe and controlled birth can be planned. Occasionally, a woman confuses stress incontinence (involuntary loss of urine on coughing or sneezing or lifting a heavy object) for this. In this situation, vaginal examination typically reveals that the membranes are still intact.
Abdominal or Chest Pain
Abdominal pain at any time is a signal that something is abnormal, so the woman should report it immediately. Some women may think that it is normal because the growing uterus is deflecting their other organs from their usual alignment, but actually the uterus expands painlessly. Abdominal pain is a sign of some other problem, such as a tubal (ectopic) pregnancy, separation of the placenta, preterm labor, or something unrelated to the pregnancy but perhaps equally as serious, such as appendicitis, ulcer, or pancreatitis. Chest pain may indicate a pulmonary embolus, a complication that can follow thrombophlebitis.

Pregnancy-Induced Hypertension (PIH)
PIH refers to a potentially severe and even fatal elevation of blood pressure that occurs during pregnancy. A number of symptoms signal that PIH is developing:
  • Rapid weight gain (over 2 lb per week in the second trimester, 1 lb per week in the third trimester)
  • Swelling of the face or fingers
  • Flashes of light or dots before the eyes
  • Dimness or blurring of vision
  • Severe, continuous headache
  • Decreased urine output
Some edema of the ankles during pregnancy is normal, particularly if it occurs after a woman has been on her feet for a long period of time. Swelling of the hands (ask if she has noticed that her rings are tight) or face (difficulty opening eyes in the morning due to edema of the eyelids) indicates edema too extensive to be normal. Visual disturbances or a continuous headache may signal cerebral edema or acute hypertension. Be certain a woman is not reporting symptoms she had before she became pregnant. If she had the same visual difficulties and headaches before pregnancy as she is reporting now, she may need to see an ophthalmologist rather than her obstetrician for help with the problem. (See Chapter 15 for more on PIH.)
Increase or Decrease in Fetal Movement
Because a fetus normally moves more or less the same amount every day, an unusual increase or decrease in movement suggests that a fetus is responding to the need for oxygen. Be sure to ask the woman about typical fetal movements and whether she has noticed any increase or decrease in this rate recently. Also emphasize the need for a woman to report any changes she notices so that further testing and follow-up can be done. Tests of fetal movement are discussed in Chapter 8.
Preventing Fetal Exposure to Teratogens
A teratogen is any factor, chemical or physical, that adversely affects the fertilized ovum, embryo, or fetus. To reach maturity in optimal health, a fetus needs sound genes (see Chapter 7) and a healthy intrauterine environment that protects it from the influence of teratogens.
At one time, it was assumed that a fetus in utero was protected from chemical or physical injury by the presence of the amniotic fluid and by the absence of any direct placental exchange between mother and fetus. When infants were born with disorders, it was attributed to the influence of fate, bad luck, or, in some cultures, evil spirits. Today, it is acknowledged that a fetus is extremely vulnerable to environmental injury. Although the causes of many anomalies occurring in utero are still unknown, many teratogenic factors have been isolated.
Effects of Teratogens on a Fetus
Several factors influence the amount of damage a teratogen can cause. The strength of the teratogen is one factor. For example, radiation is a known teratogen. In small amounts (everyone is exposed to some radiation every day, such as from sun rays), it causes no damage. However, in large doses (e.g., the amount of radiation necessary to treat cancer of the cervix), serious fetal defects or death can occur.
The timing of the teratogenic insult is another factor that makes a significant difference. If a teratogen is introduced before implantation, either the zygote is destroyed or it appears unaffected. If the insult occurs when the main body systems are being formed (in the 2nd to 8th weeks of embryonic life), a fetus is very vulnerable to injury. During the last trimester, the potential for harm again decreases because all the organs of a fetus are formed and are merely maturing. The times when different anatomic areas of a fetus are most likely to be affected by teratogens are shown in Figure 8.5.
Two exceptions to the rule that deformities usually occur in early embryonic life are the effects caused by the organisms of syphilis and toxoplasmosis. These two infections can cause abnormalities in organs that were originally formed normally.
A third factor determining the effects of a teratogen is the teratogen's affinity for specific tissue. Lead, for instance, attacks and disables nervous tissue. Thalidomide causes limb defects. Tetracycline causes tooth enamel deficiencies and, possibly, long bone deformities. The rubella virus, on the other hand, can affect many organs: the eyes, ears, heart, and brain are the four most commonly attacked.
Nursing Diagnoses
Much of the health history information obtained at prenatal visits helps to determine whether a woman has been exposed to a teratogen since the last visit.
Examples of nursing diagnoses associated with maternal exposure to teratogens are:
  • Health-seeking behavior related to mother's interest in avoiding exposure to substances harmful to a fetus during pregnancy
  • Risk for fetal injury related to lack of knowledge about teratogenicity of alcohol, drugs, and cigarettes
  • Risk for infection related to fetal transmission from maternal exposure to genital herpes
Teratogenic Maternal Infections
Teratogenic maternal infections can involve either sexually transmitted or systemic infections. Organisms that cross the placenta can be viral, bacterial, or protozoan. Most cause relatively mild, flulike symptoms in a woman but can have much more serious effects on a fetus or newborn. Preventing and predicting fetal injury from infection is complicated because a disease may be subclinical (without any symptoms in the mother) and yet may injure a fetus.

When diseases that are known to cross the placenta and cause fetal harm are tested for, they are described collectively under the umbrella term TORCH, an abbreviation for toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus. (Some sources identify the O with “other infections,” which could include syphilis, hepatitis B virus [HBV], and human immunodeficiency virus [HIV].) The TORCH screen is an immunologic survey to determine whether these infections exist in either the pregnant woman (to identify fetal risk factors) or the newborn (to detect if antibodies against the common infectious teratogens are present). Although it is now known that many more than the original four or five maternal infections can cause harm to a fetus or newborn (a chlamydia or streptococcal B infection, for example, can cause pneumonia in the newborn [see Chapter 26]), the TORCH screen still provides a quick way to assess the potential risk of teratogenic infection in pregnant women or newborns. Both hepatitis B and HIV infections are discussed in Chapter 14. TORCH screen infections are described in more detail below.
Toxoplasmosis, a protozoan infection, is spread most commonly through contact with uncooked meat, although it may also be contracted through handling cat stool in soil or cat litter (Ricci et al., 2003). A woman experiences almost no symptoms of the disease except a few days of malaise and posterior cervical lymphadenopathy. Even in light of these mild symptoms, if the infection crosses the placenta, the infant may be born with central nervous system damage, hydrocephalus, microcephaly, intracerebral calcification, and retinal deformities. If the diagnosis is established by serum analysis during pregnancy, therapy with sulfonamides may be prescribed. However, the prevention of fetal deformities is uncertain, and sulfa may lead to increased bilirubin levels in the newborn. Pyrimethamine, an antiprotozoal agent, may also be used. This drug is an antifolic acid drug, so it is administered with caution early in pregnancy to prevent reducing folic acid levels.
As many as 1 in 900 pregnancies may be affected by toxoplasmosis (Minkoff & Gibbs, 2003). Prepregnancy serum analysis can be done to identify women who have never had the disease and so are susceptible (about 50% of women). Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. On the other hand, taking in a new cat is unwise. Instruct pregnant women to avoid undercooked meat and also not to change a cat litter box or work in soil in an area where cats may defecate.
The rubella virus usually causes only a mild rash and mild systemic illness in the mother, but the teratogenic effects on a fetus can be devastating (Gerber & Hohlfeld, 2003). Fetal damage from maternal infection with rubella (German measles) includes deafness, mental and motor challenges, cataracts, cardiac defects (most commonly patent ductus arteriosus and pulmonary stenosis), restricted intrauterine growth (small for gestational age), thrombocytopenic purpura, and dental and facial clefts, such as cleft lip and palate.
Typically, a rubella titer is obtained on the first prenatal visit. A titer greater than 1:8 suggests immunity to rubella. A titer of less than 1:8 suggests that a woman is susceptible to viral invasion. A titer that is greatly increased over a previous reading or is initially extremely high suggests that a recent infection has occurred.
A woman who is not immunized before pregnancy cannot be immunized during pregnancy because the vaccine uses a live virus that would have effects similar to those occurring with a subclinical case of rubella. After a rubella immunization, a woman is advised not to become pregnant for 3 months, until the rubella virus is no longer active. Immediately after a pregnancy, assess whether a woman with low rubella titers would like to be immunized to provide protection against rubella in future pregnancies (Speroff & Fritz, 2005).
An increasing concern is women who demonstrate antibodies against rubella yet still become reinfected during pregnancy. Because of this, all pregnant women should avoid contact with children with rashes. Infants who are born to mothers who had rubella during pregnancy may be capable of transmitting the disease after birth. The infant needs to be isolated from other newborns during the newborn period. The mother should be made aware of the possibility that her infant might infect others, including pregnant women. Nurses who care for pregnant women or newborns should receive immunization against rubella to ensure that they neither spread nor contract the disease.
Cytomegalovirus (CMV), a member of the herpes virus family, is another teratogen that can cause extensive damage to a fetus while causing few symptoms in a woman (Minkoff & Gibbs, 2003). It is transmitted by droplet infection from person to person. If a woman acquires a primary CMV infection during pregnancy and the virus crosses the placenta, the infant may be born severely neurologically challenged (hydrocephalus, microcephaly, spasticity) or with eye damage (optic atrophy, chorioretinitis), deafness, or chronic liver disease. The child's skin may be covered with large petechiae (“blueberry-muffin” lesions). Because a woman has almost no symptoms, she may not be aware that she has contracted an infection. However, diagnosis in the mother or infant can be established by the isolation of CMV antibodies in blood serum. Unfortunately, no treatment for the infection exists even if it presents in the mother with enough symptoms to allow detection. Because there is no treatment or vaccine for the disease, routine screening for CMV during pregnancy is not recommended. Women can help prevent exposure by thorough handwashing before eating and avoiding crowds of young children at daycare or nursery settings.
Like herpes simplex, a primary CMV infection may become latent and then reactivate periodically. These recurrences are not thought to have a teratogenic effect on a fetus, but they can cause infection of the newborn during birth from genital secretions, or postpartum from exposure to CMV-infected breast milk. CMV infection contracted at or shortly after birth is not associated with

serious adverse effects except in babies of very low birthweight (1,200 g).
Herpes Simplex Virus (Genital Herpes Infection)
A primary, first-episode genital herpes infection in a pregnant woman poses a substantial risk to a fetus (Sheffield et al., 2004). The first time a woman contracts a genital herpes infection, systemic involvement occurs. The virus spreads into the bloodstream (viremia) and crosses the placenta to a fetus.
If the infection takes place in the first trimester, severe congenital anomalies or spontaneous miscarriage may occur. If the infection occurs during the second or third trimester, there is a high incidence of premature birth, intrauterine growth restriction, and continuing infection of the newborn at birth. Unless recognized and treated, the fetal mortality and morbidity rates are as high as 80% (Brown, 2004).
If a woman has had herpes simplex virus type 1 infections before the genital herpes invasion or if the genital herpes (type 2) infection is a recurrence, antibodies to the virus in her system prevent spread of the virus to a fetus across the placenta. If genital lesions are present at the time of birth, however, a fetus may contract the virus from direct exposure during birth. For women with a history of genital herpes and existing genital lesions, cesarean birth is often advised to reduce the risk of this route of infection. This awareness of the placental spread of herpes simplex virus has increased the importance of obtaining information about exposure to genital herpes or any painful perineal or vaginal lesions that might indicate this infection at prenatal visits.
Intravenous or oral acyclovir (Zovirax) can be administered to women during pregnancy (Karch, 2004). The primary mechanism for protecting a fetus, however, focuses on disease prevention. Urging women to practice safer sex is important to lessen their exposure to this and other sexually transmitted infections.
Other Viral Diseases
It has been difficult to demonstrate other viral teratogens, but rubeola (measles), coxsackievirus, mumps, varicella (chickenpox), poliomyelitis, influenza, and viral hepatitis all may be teratogenic. Parvovirus B19, the causative agent of erythema infectiosum (also called fifth disease), if contracted during pregnancy, can cross the placenta and attack the red blood cells of a fetus. Infection during early pregnancy is associated with fetal death. If the infection occurs late in pregnancy, the infant may be born with severe anemia and congenital heart disease (Al-Khan, Caligiuri, & Apuzzio, 2003).
Syphilis, a sexually transmitted infection, is of great concern for the maternal–fetal population despite the availability of accurate screening tests and proven medical treatment, as it places a fetus at risk for intrauterine or congenital syphilis (Dobson, 2004). Early in pregnancy, when the cytotrophoblast layer of the chorionic villi is still intact, the causative spirochete of syphilis, Treponema pallidum, cannot cross the placenta and damage the fetus. When the cytotrophoblastic layer atrophies at about the 16th to 18th week of pregnancy, the spirochete then can cross and cause extensive damage. If syphilis is detected and treated with an antibiotic such as benzathine penicillin in the first trimester, therefore, a fetus is rarely affected. If left untreated beyond the 18th week of gestation, deafness, cognitive challenge, osteochondritis, and fetal death are possible.
For this reason, serologic screening (either a VDRL or a rapid plasma reagin) should be done at the first prenatal visit; the test may then be repeated again close to term (the 8th month) if exposure is a concern. Even when a woman has been treated with appropriate antibiotics, the serum titer remains high for more than 200 days; an increasing titer, however, suggests that reinfection has occurred. In an infant born to a woman with syphilis, the serologic test for syphilis may remain positive for up to 3 months even though the disease was treated during pregnancy.
The newborn with congenital syphilis may have congenital anomalies, extreme rhinitis (sniffles), and a characteristic syphilitic rash, all of which identify the baby as high risk at birth. When the baby's primary teeth come in, they are oddly shaped (Hutchinson teeth). Medical and nursing care of the newborn with congenital syphilis is discussed in Chapter 26.
Lyme Disease
Lyme disease, a multisystem disease caused by the spirochete Borrelia burgdorferi, is spread by the bite of a deer tick. The highest incidence occurs in the summer and early fall. The largest outbreaks of the disease are found on the east coast of the United States (Eppes, 2003). After the tick bite, a typical skin rash, erythema chronicum migrans (large, macular lesions with a clear center), develops. Pain in large joints such as the knee may be present. Infection in pregnancy can result in spontaneous miscarriage or severe congenital anomalies.
Women anticipating becoming pregnant or who are pregnant should avoid areas such as wooded or tall grassy areas where they are apt to be bitten by ticks. If hiking in these areas, a woman should avoid the use of tick repellents containing diethyltoluamide because this ingredient is teratogenic. Instead, she should wear long, light-colored slacks tucked into her socks to prevent her legs from being exposed. To spread the spirochete, the tick must be present on the body possibly as long as 24 hours. After returning home from an outing, therefore, a woman should inspect her body carefully and immediately remove any ticks found. If she has any symptoms that suggest Lyme disease or knows she has been bitten, she should contact her primary health care provider immediately. Treatment of Lyme disease for pregnant women differs from that for nonpregnant women. The drugs used for nonpregnant adults, tetracycline and doxycycline, cannot be used during pregnancy because they cause tooth discoloration and, possibly, long-bone malformation in a fetus. A course of penicillin will be prescribed to reduce symptoms in the pregnant woman.
Because the symptoms of Lyme disease are chronic but not dramatic (a migratory rash and joint pain), women may not report them at a prenatal visit unless they are educated about their importance and are asked at prenatal visits if such symptoms are present.

Infections That Cause Illness at Birth
A number of infections are not teratogenic to a fetus during pregnancy but are harmful if they are present at the time of birth. Gonorrhea, candidiasis, chlamydia, streptococcus B, and hepatitis B infections are examples of these. Chapters 26 and 47 discuss the effects of these infections on maternal, fetal, and neonatal health.
Potentially Teratogenic Vaccines
Live virus vaccines, such as measles, mumps, rubella, and poliomyelitis (Sabin type), are contraindicated during pregnancy because they may transmit the viral infection to a fetus (Katz, 2003). Care must be taken in routine immunization programs to make sure that adolescents about to be vaccinated are not pregnant. Women who work in biologic laboratories where vaccines are manufactured are well advised not to work with live virus products during pregnancy.
Teratogenic Drugs
Many women, assuming that the rule of being cautious with drugs during pregnancy applies only to prescription drugs, take over-the-counter drugs or herbal supplements freely. Although not all drugs cross the placenta (e.g., heparin does not because of its large molecular size), most do. Also, even though most herbs are safe, ginseng, for example, used to improve general well-being, or senna, used to relieve constipation, may not be safe (Rousseaux & Schachter, 2003).
To identify drugs that are unsafe for ingestion during pregnancy, the U.S. Food and Drug Administration (FDA) has established five categories of safety (Table 11.1). Two principles govern drug intake during pregnancy:
  • Any drug or herbal supplement, under certain circumstances, may be detrimental to fetal welfare. Therefore, during pregnancy, women should not take any drug or supplement not specifically prescribed or approved by their physician or nurse-midwife.
  • A woman of childbearing age and ability should take no drugs other than those prescribed by a physician or nurse-midwife to avoid exposure to a drug should she become pregnant.
TABLE 11.1 Pregnancy Risk Categories of Drugs
Category Description Example
A Adequate studies in pregnant women have failed to show a risk to the fetus in the first trimester of pregnancy; there is no evidence of risk in later trimesters. Thyroid hormone
B Animal studies have not shown an adverse effect on the fetus, but there are no adequate clinical studies in pregnant women. Insulin
C Animal studies have shown an adverse effect on the fetus, but there are no adequate studies on humans, or there are no adequate studies in animals or humans. Pregnancy risk is unknown. Docusate sodium (Colace)
X Studies in animals or humans show fetal abnormalities, or adverse reaction reports indicate evidence of fetal risk. The risks involved clearly outweigh potential benefits. Isotretinoin (Accutane)
Karch, A.M. (2004). Lippincott's nursing drug guide. Philadelphia: Lippincott Williams & Wilkins.
The classic teratogenic drug is thalidomide, once liberally prescribed for morning sickness in Europe. Never approved for use in the United States, thalidomide caused amelia or phocomelia (total or partial absence of extremities) in 100% of instances when taken between the 34th and 45th day of pregnancy. Thalidomide is again available as an anti-cancer drug for use particularly with patients with multiple myeloma (Rajkumar, 2004). Patients taking this must be conscientious not to do so if they are pregnant. Other examples of drugs capable of being teratogenic are shown in Table 11.2.
The use of recreational drugs during pregnancy puts a fetus at risk in two ways: the drug may have a direct teratogenic effect, and intravenous drug use also risks exposure to diseases such as HIV and hepatitis B.
Narcotics such as meperidine (Demerol) and heroin have long been implicated as causing intrauterine growth restriction. The use of marijuana alone apparently does not, although the long-term effects of marijuana during pregnancy are still unstudied. Cocaine, particularly its crack form, is potentially harmful to a fetus because it causes severe vasoconstriction in the mother, compromising placental blood flow and so interfering with the fetal nutrient supply. Its use is associated with spontaneous miscarriage, preterm labor, meconium staining, and intrauterine growth restriction (Ogunyemi & Hernandez-Loera, 2004). Whether cocaine causes long-term effects remains controversial (Rayburn & Bogenschutz, 2004). See Chapter 17 for more information on the potential hazards of cocaine or heroin use during pregnancy.
TABLE 11.2 Some Potentially or Positively Teratogenic Drugs
Category Drug Drug Use Teratogenic Effect
Vitamin A derivatives Isotretinoin (Accutane)
Etretinate (Tegison)
Craniofacial, cardiac, CNS anomalies
Craniofacial, cardiac, CNS anomalies
Alcohol Wine, whiskey Social use Fetal alcohol syndrome
Analgesics Acetylsalicylic acid (aspirin)
Minor pain relief Prolonged pregnancy;
maternal bleeding
Patent ductus arteriosus
Antineoplastics Methotrexate
Cyclophosphamide (Cytoxan)
Multiple anomalies
Multiple anomalies
Androgens Danazol Endometriosis Masculinization of female fetus
Anticonvulsants Phenytoin (Dilantin)
Valproic acid
Seizures Fetal hydantoin syndrome
Neural tube defects
Neural tube defects
Possibly fetal anomalies
Anticoagulants Warfarin (Coumarin) Anticoagulation Fetal bleeding or anomalies
Antidepressants Imipramine (Tofranil) Elevate mood Cardiovascular anomalies
Antischizophrenic Lithium Schizophrenia Hydramnios
Antithyroid Methimazole Hypothyroidism Hypothyroidism in fetus
Antibiotics Ribavirin
Respiratory infection
Multiple anomalies
Hyperbilirubinemia in newborn
Teeth and bone deformities
Antihelmintics Lindane Eradication of lice Manufacturer recommendation of
limiting exposure to 2 doses
Angiotensin-converting enzyme inhibitors Enalapril (Vasotec)
Captopril (Capoten)
Reduce hypertension Oligohydramnios
Caffeine Caffeine Coffee, soft drinks, chocolate Low birthweight
Hypoglycemics Tolbutamide (Orinase) Type II diabetes Profound hypoglycemia in newborn
Diagnostic studies May destroy thyroid of fetus
Narcotics Cocaine
Social pleasure Dysmorphic and CNS anomalies
Growth retardation; narcotic withdrawal in newborn
Tranquilizers Benzodiazepine (diazepam) Reduce anxiety Growth retardation; CNS dysfunction
Hypotonia, respiratory depression
Vaccines (live) Rubella Provide immunity Possible infection in fetus
Yankowitz, J. (2003). Drugs in pregnancy. In J.R. Scott, et al. Danforth's obstetrics and gynecology (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

An area of recreational drug use that needs to be examined is that of inhalant abuse (“huffing”). Substances frequently used as inhalants include gasoline, butane lighter fluid, Freon, glue, and nitrous oxide (NIOSH, 2000). Although the teratogenic properties of inhalants are not well studied, they all carry the possibility of respiratory distress, which could limit the oxygen supply to a fetus.
Teratogenicity of Alcohol
Evidence over the years has shown that when women consume a large quantity of alcohol during pregnancy, their babies show a high incidence of congenital deformities and cognitive impairment. It was assumed that these defects were the result of the mother's poor nutritional status (drinking alcohol rather than eating food), not necessarily

the direct result of the alcohol. However, alcohol has now been firmly isolated as a teratogen. Fetuses cannot remove the breakdown products of alcohol from their body. The large buildup of these leads to vitamin B deficiency and accompanying neurologic damage.
Women during pregnancy should be screened for alcohol use because an infant born with fetal alcohol syndrome is not only small for gestational age but can be cognitively challenged (Mukherjee et al., 2005). The infant typically has a characteristic craniofacial deformity including short palpebral fissures, a thin upper lip, and an upturned nose (Yankowitz, 2003). Because of individual variations in metabolism, it is impossible to define a safe level of alcohol consumption. Women are best advised, therefore, to abstain from alcohol completely. Women with alcohol addiction should be referred to an alcohol treatment program as early in pregnancy as possible to help them reduce their alcohol intake (Box 11.10).
Teratogenicity of Cigarettes
Cigarette smoking is associated with infertility in women. Cigarette smoking by a pregnant woman has been shown to have teratogenic effects on a fetus, especially growth restriction (Katz, 2003). In addition, these children may be at greater risk than others for sudden infant death syndrome. Low birthweight in infants of smoking mothers results from vasoconstriction of the uterine vessels, an effect of nicotine that limits the blood supply to a fetus. Another contributory effect may be related to inhaled carbon monoxide. Secondary smoke, or inhaling the smoke of another person's cigarettes, may be as harmful as actually smoking


the cigarettes. All prenatal health care settings should be smoke-free environments for this reason.
If a woman cannot stop smoking during pregnancy (and, realistically, many women cannot), reducing the number of cigarettes smoked per day should help diminish adverse effects on a fetus as well as also protect a woman's own health from long-term illnesses such as chronic respiratory diseases.
The best way to urge women to discontinue smoking is to educate them about the risks to themselves and their fetus at the first prenatal visit. It may be effective to encourage women to sign a contract with a health care provider to try to stop or to join a smoking-cessation program. Be certain pregnant women know that they should not enter a stop-smoking program that uses drug therapy such as nicotine patches, because the substitute drug may be as harmful to a fetus as smoking.
Environmental Teratogens
Teratogens from environmental sources can be as damaging to a fetus as those that are directly or deliberately ingested. Women can be exposed to these through contact at home or at work sites. For example, washing children's hair with a shampoo such as lindane (Kwell) to remove lice should be limited to two exposures because of potential toxicity (Karch, 2004).
Metal and Chemical Hazards
Pesticides and carbon monoxide such as from automobile exhaust are examples of chemical teratogens that are harmful and so should be avoided. Arsenic, a byproduct of copper and lead smelting, used in pesticides, paints, and leather processing; formaldehyde, used in paper manufacturing; and mercury, used in the manufacture of electrical apparatuses, are all teratogens that can be contacted at work sites. Additional information on specific chemicals can be obtained from the National Institute for Occupational Safety and Health (NIOSH) at their web site (
Lead poisoning generally is considered a problem of young children eating lead-based paint chips, but it also can be a fetal hazard. Women may ingest lead by drinking water that travels through old pipes that are leaching lead or by “sniffing” gasoline. Lead ingestion during pregnancy may lead to a newborn who is cognitively or neurologically challenged (Hackley & Katz-Jacobson, 2003).
Rapidly growing cells are extremely vulnerable to destruction by radiation. Radiation has been proven to be a potent teratogen to unborn children because of the high proportion of rapidly growing cells present. It produces a range of malformations depending on the stage of development of the embryo or fetus and the strength and length of exposure. If the exposure occurs before implantation, the growing zygote apparently is killed. If the zygote is not killed, it survives apparently unharmed. The most damaging time for exposure and subsequent damage is from implantation to 6 weeks after conception (when many women are not yet aware that they are pregnant). The nervous system, brain, and the retinal innervation are most affected.
As a rule, therefore, all women of childbearing age should be exposed to pelvic x-rays only in the first 10 days of a menstrual cycle (when pregnancy is unlikely because ovulation has not yet occurred), except in emergency situations. A serum pregnancy test can be done

on all women who have reason to believe they might be pregnant before diagnostic tests involving x-rays are performed.
Radiation of the pelvis should be avoided all during pregnancy if possible. It should be undertaken only at term if the data obtained are important for birth and cannot be obtained by any other means. Sonography and magnetic resonance imaging have replaced x-ray examination for confirmation of situations such as multiple pregnancy because these do not appear to be teratogenic.
In addition to immediate fetal damage, evidence exists that radiation can have long-lasting effects on the health of the child. There appears to be an increased risk of cancer in children exposed to radiation in utero. Exposure of the fetal gonads could lead to a genetic mutation that will not be evident until the next generation (Katz, 2003).
If a woman needs non-pelvic radiation during pregnancy (e.g., dental x-rays, arm or leg x-ray after a fall), she should be given a lead apron to shield her pelvis during the procedure. Even fluoroscopy, which uses lower radiation doses than regular x-ray photography, can cause fetal deformities and should be avoided during pregnancy—again, except in an emergency. Although still being investigated, long-term use of slight radiation sources, such as a word processor, computer, or cellular phone, does not appear to be teratogenic.
Hyperthermia and Hypothermia
Hyperthermia to a fetus may be detrimental to growth because it interferes with cell metabolism. Hyperthermia can occur from the use of saunas, hot tubs, or tanning beds, or from a work environment next to a furnace, such as in welding or steel making. For this reason, pregnant women should avoid hot tubs or saunas. Women who use a hot tub at 40°C should not stay in it for longer than about 10 minutes at one time. Maternal fever early in pregnancy (4 to 6 weeks) may cause abnormal fetal brain development and possibly seizure disorders, hypotonia, and skeletal deformities (Edwards, Saunders, & Shiota, 2003).
The effect of hypothermia on pregnancy is not well known. Because the uterus is an internal organ, a woman's body temperature would have to be lowered significantly before a great deal of fetal change would result.
Teratogenic Maternal Stress
Many myths exist about the effect of being frightened or surprised while pregnant. For example:
  • If a woman sees a mouse during pregnancy, her child will be born with a furry or molelike birthmark.
  • Eating strawberries causes strawberry birthmarks.
  • Looking at a handicapped child while pregnant will cause a child in utero to be handicapped the same way.
Common sense and awareness of fetal–maternal physiology have dispelled these superstitions. There is some evidence, however, that an emotionally disturbed pregnancy, one filled with anxiety and worry beyond the usual amount, could produce physiologic changes through its effect on the sympathetic division of the autonomic nervous system. The primary changes this could cause include constriction of the peripheral blood vessels (a fight-or-flight syndrome). If the anxiety is prolonged, the constriction of uterine vessels (the uterus is a peripheral organ) could interfere with the blood and nutrient supply to a fetus.
These phenomena are characteristic only of long-term, extreme stress, not of the normal anxiety of pregnancy. Illness or death of one's partner, difficulty with relatives, marital discord, and illness or death of another child are examples of stressful situations that might provoke excessive anxiety.
Helping a woman resolve these complex problems during pregnancy is not easy. If maternal stress is severe, however, securing counseling is as important as ensuring good physical care.
Preparing for Labor
At about the midpoint of pregnancy, along with cautioning women about discomforts of pregnancy and possible teratogen situations, it is time to review the events that signal the beginning of labor so that women will not be surprised by these happenings or dismiss them as something other than what they are.
Lightening is the settling of the fetal head into the inlet of the true pelvis. It occurs approximately 2 weeks before labor in primiparas but at unpredictable times in multiparas. A woman notices she is not as short of breath as she was. Her abdominal contour is definitely changed, and on standing she may experience frequency of urination or sciatic pain (pain across her buttock radiating down her leg) from the lowered fetal position.
Show is the common term used to describe the release of the cervical plug (operculum) that formed during pregnancy. It consists of a mucous, often blood-streaked vaginal discharge and indicates the beginning of cervical dilatation.
Rupture of the Membranes
A sudden gush of clear fluid (amniotic fluid) from the vagina indicates rupture of the membranes. A woman should telephone her primary care provider immediately when this occurs. After rupture of the membranes, there is a danger of cord prolapse and uterine infection.
Excess Energy
Feeling extremely energetic is a sign of labor important for women to recognize. It occurs as part of the body's physiologic preparation for labor. If a woman does not recognize the sensation for what it is, she may use this burst of energy to clean her house or finish paperwork at the office and exhaust herself before labor begins. If she can recognize this symptom as an initial sign of labor, she can conserve her energy in preparation for labor.

Uterine Contractions
For most women, labor begins with contractions. True labor contractions usually start in the back and sweep forward across the abdomen like the tightening of a band. They gradually increase in frequency and intensity. Advise a woman to telephone her primary care provider when contractions begin to alert health care personnel that she is in labor. Inform her at what point in labor her physician or nurse-midwife wants her to come to the health care facility (such as when contractions are 5 minutes apart). Be certain she knows this is not a hard-and-fast rule, however. If she should become exceptionally anxious, be home alone, or have a long drive, she should be given the option of using common sense to determine when to leave home.
Key Points
  • Prenatal education is an important part of prenatal care. The more women know about measures they should take during pregnancy to safeguard their health, the more likely they will avoid substances or activities harmful to fetal growth.
  • Urge women to find the best way for them to modify their lifestyle for pregnancy. Pregnancy is 9 months long, so modifications must be agreeable to a woman or she will not maintain them over such a long time span.
  • Discussion and health-teaching periods during pregnancy should cover self-care topics such as bathing, sexual activity, sleep, and exercise.
  • Women need to make provisions for rest periods during their day and to be aware of any potential teratogens at a work site, such as exposure to radiation or heavy metals.
  • Women who travel should plan for break periods to avoid congestion in the lower extremities. Seat belts should be used when traveling by car.
  • Common discomforts of early pregnancy include breast tenderness, constipation, palmar erythema, nausea and vomiting, fatigue, muscle cramps, pain from varicosities or hemorrhoids, heart palpitations, frequency of urination, and leukorrhea. If women know that these symptoms may occur, they will not interpret them as complications.
  • Minor discomforts of middle or late pregnancy include backache, dyspnea, ankle edema, and Braxton Hicks contractions. Caution women that contractions could be a sign of labor.
  • Danger signs for women to report during pregnancy are vaginal bleeding, persistent vomiting, chills and fever, escape of fluid from the vagina, abdominal or chest pain, swelling of the face and fingers, vision changes or continuous headache, rhythmic cramping, burning with urination, or a pronounced decrease in fetal movement.
  • Women should take active measures to avoid exposure to infectious diseases such as rubella, HIV, cytomegalovirus, herpes simplex virus, syphilis, Lyme disease, and toxoplasmosis during pregnancy.
  • Counsel women about the necessity to avoid the use of any drugs or herbal supplements not specifically approved by their physician or nurse-midwife during pregnancy, as well as alcohol and cigarettes.
  • It is almost impossible for a woman to modify a behavior, such as smoking, if her support person does not agree to change also. Including the family in care is an important way of helping support persons understand the need for the modification and increasing cooperation.
  • Beginning signs of labor for which the pregnant woman should be alert include lightening, show, excess energy, rupture of membranes, and uterine contractions.
Critical Thinking Exercises
  • Julberry Adams, the woman you met at the beginning of the chapter, voiced a number of concerns, including whether she should stop work and whether it would be safe to take a long trip. What advice would you give her regarding these questions?
  • Although Julberry describes a day she says involves a lot of walking, she also has long periods of sitting with almost no exercise. What would be some recommendations you could make to help her prevent blood clots from the sharp bend in her knee while sitting?
  • Julberry is having trouble remembering to take her prenatal vitamin. What are some suggestions you could make to help her remember to take this daily?
  • Examine the National Health Goals related to prenatal care. Most government-sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore pertinent to these goals that would be applicable to Julberry and her family and also advance evidence-based practice?

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