Maternal-Newborn Nursing DeMYSTiFieD: A Self-Teaching Guide

UNIT I

Roles and Relationships

CHAPTER 1

Overview of Maternity Nursing

Objectives

At the end of this chapter the student will be able to:

Discuss the focus of maternal-newborn nursing.

Identify the varied roles a nurse may assume when caring for the childbearing family.

Discuss the steps of the nursing process in the care of the childbearing family.

Discuss the phases of maternal-newborn nursing.

Determine the impact of maternal growth and development stage on family planning and the care provided to the childbearing family.

KEY TERMS

Antipartum phase

Certified nurse-midwife (CNM)

Clinical nurse specialist (CNS)

Family planning phase

Intrapartum phase

Licensed practical/licensed vocational nurse (LPN/LVN)

Nurse practioner (NP)

Puerperium

Maternal-newborn nursing focuses on the experience and care of a woman, family, and newborn before, during, and after a pregnancy. Care for the woman of childbearing age may begin prior to conception with planning for pregnancy and addressing issues related to fertility. A family-centered approach is essential to ensure that the primary needs of the childbearing woman and the newborn are fully addressed. The family provides the source of support and resources for the mother and child; thus the stability, or lack of stability, of the family can greatly impact the maternal-child experience before, during, and after pregnancy. The cultural background of the family also greatly impacts the experience of pregnancy and childbirth. Cultural norms should be respected and, when possible, integrated into the plan of care for the childbearing family.

The nurse’s role in the care of the childbearing family can vary depending on the stage of the woman and family in the childbearing process. Prior to conception, the role of the nurse may be focused on assisting the woman and mate with family planning or addressing fertility issues. After conception and through delivery, the nurse is focused on supporting a healthy pregnancy through health promotion measures including proper nutrition, rest, and activity to benefit the mother and fetus. The nurse may work with the family in the following capacities.

Licensed practical/licensed vocational nurse (LPN/LVN): A technical nurse who has completed a program in a technical school or community college setting and passed the National Council Licensure Examination (NCLEX) for LPN/LVNs. The LPN/LVN may assist in a clinic, in a doctor’s office, or in the hospital setting, often under the direction of a licensed registered nurse, nurse practitioner, or physician, and may assist with preparation of the childbearing female for the pregnancy and delivery process.

Registered nurse (RN): A professional nurse who has graduated from an accredited nursing program and passed the NCLEX for RNs. The RN may plan and provide care for the childbearing family from initial contact, beginning with gathering of assessment data and providing teaching, to monitoring the progression of the pregnancy through delivery, and assisting the new family in the adjustment process with the newborn.

Nurse practioner (NP): An advanced practice nurse who provides care to the childbearing family beginning with diagnosis and addressing of fertility issues with referral to appropriate specialists as needed, through delivery of the newborn and care of the neonate, and the postdelivery care for the new mother and family, including lactation guidance. The NP may specialize in women’s health; family (FNP), focusing on all members of a family from birth to old age; the neonate (NNP), caring for the normal or high-risk newborn; or the pediatric client as the newborn grows (PNP).

Certified nurse-midwife (CNM): An advanced practice nurse who is often educated at the master’s level and has passed a certification test in the area of pregnancy and labor-delivery. The CNM provides care for the childbearing woman during pregnancy and through labor and delivery.

Clinical nurse specialist (CNS): An RN who has obtained advanced education and clinical preparation at the master’s level with a focus on the educator, manager, and researcher roles relative to patient care. The CNS may provide care to the childbearing family during the family planning phase, and through pregnancy and delivery, care of the newborn and postdelivery mother and family, and post discharge during the adjustment period with the newborn, including issues with lactation and refining parenting skills.

THE NURSING PROCESS

Nursing care is provided through the use of the nursing process, which provides a guide for comprehensive planning and provision of care to the childbearing family. After years of practice, the steps of the process might not be outlined distinctly as the nurse proceeds, but will remain the foundation for care. The process includes:

Assessment of the client and family relative to the problem and related concerns, as well as underlying family dynamics that could impact support and resources needed during the childbearing process.

Development of nursing diagnoses, which are statements that define the problems and potential problems indicated by the assessment findings. The North American Nurses Diagnosis Association International (NANDA-I: http://www.nanda.org) has established a list of standard diagnoses for use by nurses for planning and communication about client care.

Determining the desired outcome of care and treatment—generally resolution, to the greatest degree possible, of the problem identified by the nursing diagnosis. Knowing the objective of the care, the desired outcome, helps to guide the activities needed and gives a basis for evaluating the success of the care.

Nursing interventions designed to help the client and family meet the desired outcome of resolving the problem(s) from their condition. Interventions include care to the client as well as client and family teaching. Continued monitoring and assessment is also an expected nursing intervention for comprehensive client care.

Evaluation, and revision as indicated. This is the final stage of the nursing process. Data are gathered and continued monitoring is used to determine the degree to which outcomes were met and the need to revise goals or interventions. New nursing diagnoses may be discovered, and old nursing diagnoses may be deleted after reviewing data from continued monitoring and evaluation.

Maternal-newborn nursing encompasses several phases:

Family planning phase: Involves the childbearing female from pubescence, with information on menstruation and avoidance of unwanted teen pregnancy, through addressing issues with infertility and preparation for conception and a health pregnancy

Antipartum phase: The period from conception until the beginning of labor

Intrapartum phase: The labor stages through the delivery of the newborn and placenta

Postpartum phase (puerperium): The stage after delivery of the placenta through 6 weeks following delivery

FAMILY PLANNING

The focus in family planning is to promote optimal well-being of the child-bearing family including the health of the mother from conception through delivery, the safe and healthy delivery of a healthy newborn, or care of the high-risk newborn if indicated, and the establishment of a stable new family unit. Issues related to contraception, fertility, and other prepregnancy concerns are discussed in a later chapter.

The growth and development stage of the childbearing female greatly impacts the issues of conception being addressed in this stage. Of particular concern are pregnancy at a young age and pregnancy after the age of 40, both of which can increase the risk of complications.

CHILD OR ADOLESCENT PREGNANCY

Although the adolescent female is of childbearing age, the focus of nursing intervention at this time is frequently on prevention of unwanted pregnancy or comprehensive care in the case of teen pregnancy. Knowledge and consideration of a child’s developmental stage can contribute to planning of age-appropriate care, particularly during pregnancy. Recognition that the stress of pregnancy can impact the child’s growth and development allows the nurse to anticipate developmental disruption or regressions and plan care accordingly.

Potential Concerns

Risky behaviors, encouraged by peer pressure, i.e., violence, homicide, reckless driving, excessive and unprotected sexual intercourse, smoking, and substance abuse present a danger to the mother and fetus in child or adolescent pregnancy.

Mental health problems including depression, suicide, and eating disorders can lead to adolescent or fetal mortality or morbidity.

Pregnancy can result in shame and decreased self-esteem due to feeling of being judged by adults and peers.

Poor eating practices and decreased exercise contribute to malnourishment in the mother and fetus.

Facial and body acne, aggravated by stress and hormones, is common in teens.

Depression may be noted with higher levels in girls than boys:

• Poor peer relations, depressed or emotionally unavailable parents, parental marital conflict or financial problems, family disruption through divorce, and poor self-image are contributing factors.

Suicide ideation may manifest, particularly with fear related to parental reaction to pregnancy:

• Preoccupation with themes of death

• Talks of own death and desire to die

• Loss of energy; exhaustion without cause

• Flat affect; distant from others, social withdrawal

• Antisocial or reckless behavior—alcohol, drugs, sexual promiscuity, fights

• Change in appetite noted

• Sleeping pattern changes noted, too little or too much

• Decreased interest or decreased ability to concentrate

• Gives away cherished items

Key issues in teen pregnancy include the following:

• Emotional immaturity may decrease the teen’s ability to cope with the responsibilities associated with pregnancy and motherhood.

• Family support may be limited in unwanted pregnancy; this may be exacerbated by poverty or family dysfunction prior to the added stressor of teen pregnancy.

• Nutritional needs are increased for the pregnant adolescent. Adolescent development is incomplete, resulting in a higher need for nutrients and a competition between the mother and infant often resulting in premature births, underweight newborns, malnourished mothers, and higher infant mortality:

º Maternal intake determines the adequacy of fetal nutrition and development. Deficits for the mother result in deficits for the fetus.

º Nutritional intake of the adolescent is frequently lacking in sufficient amounts of iron, calcium, and folic acid, which are highly important to developing muscles and bones and reproductive health.

º The teen diet is often deficient in vitamins A, D, B12 and zinc; thus vitamin supplements are critical for the pregnant adolescent.

º Nutrition counseling should involve the teen, the expectant father, and the families of the mother and father to ensure that proper nutrition is supported before and after the baby is born.

Nurse Alert Teen nutritional intake is irregular; thus assessment of the teen’s nutritional intake should be done over time and not involve just a 24-hour journal to determine eating habits.

• Teen pregnancy may be associated with other high-risk adolescent behaviors such as drinking and drug use; thus a thorough assessment is needed and a plan of care should be developed to address any lifestyle habits that endanger the mother or fetus.

• Family dysfunction and abuse of the teen at home may place the adolescent mother at high risk for becoming an abusive parent or, at a minimum, establishing poor parenting skills.

Implications for Nursing Care

Effective interventions for teen clients must involve the teen in the planning and implementation.

All levels of development are important from physical to cognitive to psychosocial.

Developmental stage theories are not specific for age, but include age ranges that may overlap.

The stress of pregnancy and parenthood at a young age can cause reversal to a younger developmental stage for a brief period.

Nursing measures, including client and family teaching, must consider the developmental stage the child is demonstrating.

Teach adolescents and family members strategies to reduce health-compromising behaviors and address peer pressure.

Monitor for signs and plan interventions to address depression and suicidal ideation.

Relate health-enhancing behaviors, such as nutritious eating, regular exercise, and driving safety with use of seat belts, to improved physical appearance and promoting a healthy pregnancy and delivery.

Assist the teen in planning an appropriate balance of activity and rest during pregnancy to minimize disruption of activities with peers.

Provide opportunities for communication with the adolescent in the absence of parents to allow asking of personal questions.

Daily hygiene and treatment with acne medication can reduce outbreaks, with caution to avoid any substances that may be harmful to the fetus.

Age-appropriate care and teaching can reduce stress that the pregnant child or adolescent may experience during the growth and development process.

Family interactions, or lack thereof, can impact growth and development and are particularly important to support a new adolescent mother in developing and sustaining good parenting skills.

PREGNANCY AFTER THE AGE OF 40

Increasing numbers of women, some of whom are career focused, are engaged in a second marriage, or have other life situations, decide to wait to conceive and have a child. Modern health care has greatly improved the outcomes for these women, with less mortality and morbidity resulting. However, pregnant women over the age of 40 may frequently be viewed as high risk, and may experience family disruption secondary to a mate who is unsupportive of the concept of childrearing in later life, or older children who are unprepared to share their parental support with a new sibling. Erikson’s developmental stage of generativity versus self-absorption/stagnation indicates some behaviors that may be manifested by most women considering pregnancy or who are expectant mothers after the age of 40. For many women during this developmental stage career has been a major focus and may have been the reason for the delay in having children, but thoughts shift to caring for others and preparing the next generation. The woman and childbearing family must deal with conflicting demands, including fiscal needs for a two-person income or needs of aging parents. While focused on the pregnancy the woman may also feel the need to remain productive in her job, community, and other activities.

Key issues in pregnancy after the age of 40 include the following:

• Difficulty conceiving with increased risk of miscarriage or stillbirth

• Increased risk of complications during pregnancy, with higher risk in women with chronic illness or obesity

• Higher risk of developing diabetes secondary to pregnancy (gestational)

• Higher risk of pregnancy-induced hypertension

• Increased risk of developing preeclampsia (toxemia of pregnancy)

• Increased risk of requiring a caesarian section

• Increased risk of placenta previs

• Higher risk of delivering a child with a genetic/chromosomal abnormality, such as Down syndrome, possibly because the DNA in a woman’s eggs is damaged over time (the risk rises as age increases)

• Developing a realistic plan for activity and rest during the pregnancy and balancing obligations during and after the adjustment period when mother and newborn are discharged home, which promote a healthy pregnancy and development of effective family management and parenting skills

Implications for Nursing Care

Effective family planning is the first line of defense against potential problems. Educating the prospective mother/parents on the dangers of pregnancy after 40 increases awareness of possible complications and allows for preparation and informed choices.

Assessment of the woman’s preconception state allows for targeted efforts to improve health, prior to attempts to become pregnant.

Harmful habits, such as smoking or substance abuse, including alcohol or nonprescription drugs, should be discontinued to provide the greatest chance of a healthy pregnancy.

Obtaining optimal nutritional status and weight management is key to minimize the possible incidence of complications such as gestational diabetes or preeclampsia/toxemia.

Blood testing for rubella titer and testing for other infections allow for early intervention to prevent fetal exposure to infections that could lead to miscarriage, stillbirth, or birth defects.

Genetic counseling is beneficial to alert the prospective mother/parents of the risks of genetic abnormality related to older age. Family history should be examined to detect data that might indicate higher risk.

Close monitoring after conception throughout the pregnancy allows for early detection of problems and early intervention to minimize harm to the fetus and protect the health of the mother.

ROUTINE CHECKUP

1. What is an accurate description of an advanced practice role in the care of the childbearing family?

a. Licensed practical nurse

b. Registered nurse

c. Certified nurse-midwife

d. Licensed vocational nurse

Answer:

2. Explain why adolescent pregnancy places the mother and child at risk for health problems.

Answer:

CONCLUSION

Factors related to family and community can positively or negatively impact the care of the childbearing family. The nurse should deliver family-centered care to ensure that support systems are maximized and not disrupted so that the childbearing family receives needed support prior to and throughout the pregnancy and through their return to the home and community. Several key points should be noted from this overview chapter:

1. Provision of family-centered care will require the use of an organized nursing process to gather assessment data and plan age-appropriate interventions for the childbearing family.

2. The nurse’s role in the care of the childbearing family will vary based on the level of the nurse. The levels include licensed practical nurse, registered nurse, nurse practitioner (women’s health, family, neonatal, or pediatric), certified nurse-midwife, or clinical nurse specialist.

3. Maternal-newborn nursing encompasses the family planning, antipartum, intrapartum, and postpartum/puerperium phases.

4. Family planning is focused on the optimal well-being of the childbearing family.

5. Performing family and community assessments is useful to identify contributing factors to possible problems with conception, support needed for the childbearing family, and risk factors for problems during pregnancy or after delivery. This assessment facilitates follow-up in the community or home setting after discharge.

6. Support the childbearing family with particular considerations for the adolescent or younger, or the older mother. If the mother is a child or adolescent, or is over the age of 40, complications may result that will impact the childbearing and childrearing process.

7. Nutritional assessment and support are important for a healthy pregnancy, particularly if the mother is a child or adolescent.

8. Pregnancy after 40 years of age can present physical and emotional challenges for the childbearing family.

FINAL CHECKUP

1. Which factors should be considered when a nurse assesses a pregnant client’s growth and development? Select all that apply.

a. Food preferences

b. Language skills

c. Religious preference

d. Changes in personality and emotions

2. What is the major reason the family-centered approach is important when addressing the needs of the pregnant client?

a. Most insurance is acquired through a family plan.

b. Pregnancy involves a mother, father, and child.

c. A lack of family stability can impact the pregnancy experience for the mother and fetus.

d. Most hospitals require that the family be included in the patient plan of care.

3. What roles could a nurse assume in family planning?

a. Educator addressing issues of fertility

b. Delivery room nurse

c. Primary care provider

d. a and b

e. All of the above

4. Which nurse could serve as a primary care provider for a pregnant woman?

a. Patricia, who is a licensed practical nurse

b. Bryan, who is a registered nurse

c. Lee, who is a certified nurse-midwife

d. None of the above

5. What would be the most appropriate desired outcome for a pregnant woman who is homeless and comes to the clinic for her first prenatal visit at 26 weeks gestation in a state of obvious malnutrition?

a. The woman will eat three nutritious meals each day.

b. The woman will get a job and buy a home.

c. The woman will give her baby to a family that can support it.

d. The woman will return to the clinic on a weekly basis.

6. The family planning phase would include what activities?

a. Delivering a healthy baby

b. Discussing contraception

c. Providing care during menopause

d. All of the above

7. Alecia is admitted to the clinic in active labor. She is in what phase of pregnancy?

a. Puerperium phase

b. Intrapartum phase

c. Antipartum phase

d. Postpartum phase

8. What is a major reason that the developmental stage of an expectant female could have an impact on the pregnancy?

a. None, really. The fetal developmental stage is more important.

b. If the female is still living at home, her mother can parent the newborn.

c. The female who is an adolescent will have nutritional and emotional needs that may conflict with the needs of pregnancy.

d. The older female has completed all of her developmental stages by the age of 40 and can focus more on the needs of a newborn.

9. Clara, age 14, is admitted for dehydration secondary to continued vomiting in her first trimester of pregnancy. The nurse notes that Clara has her teddy bear and clings to her mother’s arm. What would be the most likely explanation for Clara’s behavior?

a. The stress of pregnancy has caused Clara to revert to a younger developmental stage.

b. Clara’s overprotective mother has spoiled Clara, which is why she is pregnant.

c. The pregnancy has affected Clara’s brain and caused her to become retarded.

d. Clara is trying to deny that she is pregnant by acting like a baby herself.

10. Ellisha, age 13, is pregnant and is admitted after experiencing diarrhea for the past 4 days. She is sullen and speaks only when her mother pushes her to answer questions. What should the nurse keep in mind when assessing Ellisha?

a. Ellisha likely has a communication deficit due to complications of pregnancy.

b. Ellisha would be more responsive to the nurse if her mother were absent.

c. Ellisha’s behavior is not important since her chief complaint is diarrhea.

d. Ellisha is an adolescent and may also be quiet and sullen when she is well.

ANSWERS

Routine Checkup

1. c

2. Adolescents are still undergoing physical and emotional development with demands for calories and nutrients that may compete with the needs of the fetus and decreased coping mechanisms for handling the stressors of pregnancy and parenthood. The nutritional intake of a teen is inconsistent, leading to possible nutritional deficit and premature birth or low-weight neonate.

Final Checkup

1. b and d

2. c

3. e

4. e

5. a

6. b

7. b

8. c

9. a

10. d

CHAPTER 2

Families and Communities

Objectives

At the end of this chapter the student will be able to:

Describe the impact of family dynamics on nursing care of the maternity client.

Distinguish the types of families in a community.

Contrast the health-related concerns for the childbearing family resulting from families and communities at varied socioeconomic levels.

Indicate appropriate nursing approaches to address family and community concerns related to the care of a family addressing pregnancy.

Discuss ethnic-cultural influences on family and community dynamics.

Determine appropriate nursing implications of ethnic-cultural concepts.

KEY TERMS

Assimilated family

Cohabitation family

Ethnocentric behavior

Extended family

Gay/lesbian family

High-risk population

Nuclear family

Reconstituted/binuclear family

Sibling

Stereotyping

Subculture

OVERVIEW

The family and community greatly impact the experience stability of a childbearing family. Health promotion, maintenance, and restoration activities can be supported or hindered by family dynamics and the presence or absence of family and community support resources. Challenges presented by family or community distress can severely limit the stability of the childbearing family prior to, during, or after pregnancy and adjustment to parenthood. Understanding the basic concepts of family and community dynamics helps the nurse to provide comprehensive care to a childbearing family.

Foundational concepts

• Family-centered nursing recognizes family support as a needed factor for stability in the childbearing family.

• The family, in addition to the expectant mother, is supported throughout the childbearing experience.

• Collaboration with family is facilitated throughout hospital, community, and home care.

• Family advocacy includes enabling families to build on current strengths and helping them maintain a sense of control over their lives.

• In the home setting, the nurse is a visitor and should respect the authority of the family.

• Community support resources are crucial for childbearing families with special needs—teen pregnancy, late pregnancy, or pregnancy with complications such as an expectant mother with illness or disability.

Roles and relationships

• Family members often play more than one role in the family system. Family roles:

º Include but are not restricted to parent (mother, father, stepmother, stepfather, foster parent), child, sibling, provider, homemaker, or caregiver.

º Vary depending on type and structure of the family, including number and age of members and ethnic-cultural background.

º May change as a result of the pregnancy or the changes in the needs of the expectant mother—the mother may be unable to work when her income is essential to pay family bills. Pregnancy can cause stress in a family and that stress can in turn result in the distress of mother and fetus.

TYPES OF FAMILIES

Types of families may be described in different ways and needs may vary based on family composition and function. The types of childbearing families may include:

Nuclear family: Husband (usually the provider), wife (usually home-maker, though frequently works also), and child/children.

Reconstituted/binuclear/blended family: Consists of a child or children and one parent in one home and another parent in a different home. A step-parent and step-siblings may be present in one or both homes, reconstituting two families into one and resulting in two blended nuclear families.

Cohabitation family: Consists of a man and woman who live together with a child or children without being married.

Single-parent family: Consists of a man or woman living with one or more children.

Gay/lesbian family: Two men or two women who live together as parents to one or more biological or adopted children.

Extended family: Multigenerational groups consisting of parents and children with other relatives, i.e., grandparents, aunts, uncles, cousins, grandchildren.

NURSING IMPLICATIONS

Perform a family assessment to determine the presence or absence of support for the expectant mother and father during and after hospitalization.

Identify and collaborate with key individuals within the family unit to promote restoration and maintenance of stability for the childbearing family after the mother and newborn are discharged home.

Involve parents and family in care activities with the newborn to promote learning of after-discharge care.

Assess the home environment and determine the presence of factors contributing to risk for the pregnant client or the newborn after discharge from the hospital.

Collaborate with family members to minimize risk factors and prepare the home environment to meet the needs of the expectant mother prior to delivery and the mother and newborn following discharge.

Develop an action plan that addresses the needs of the childbearing family from admission through discharge back into the community and home setting.

SOCIAL AND ECONOMIC FACTORS

Social factors such as living environment and community relationships, in addition to economic factors such as poverty, unemployment, or homelessness, can impact the health and stability of the childbearing family due to limited access to clean water, food, shelter, or health care. Some groups