CARE of MOTHER, CHILD, and ADOLESCENT

LECTURE / P1 NOTES: SAS 1-11 / NUR 194

Lesson #1
Framework for maternal and child health
nursing and concepts of unitive and
procreative health
1. Primary goal of maternal and child health nursing:
- Promotion and maintenance of optimal family health to
ensure cycles of optimal childbearing and child rearing
Maternal and child health nursing practice
throughout the childbearing-childrearing
continuum
 Provision of preconception health care
 Provision of nursing care of women throughout
pregnancy, birth, and postpartum periods
2. Philosophy of maternal and child health nursing:
 CARE of MOTHER, CHILD, and ADOLESCENT
LECTURE / P2 NOTES: SAS 12-23 / NUR 194

Lesson #12  The pubic arch forms an acute angle, making the lower
dimensions of the pelvis extremely narrow
Components of labor  Fetus may have difficulty exiting from this type of pelvis
5 P’s ANTHROPOID “APE-LIKE”
1. pelvis (THE passage) – the woman’s PELVIS (the  Transverse diameter is narrow; anteroposterior diameter of the
inlet is larger than usual
PASSAGE) is of adequate size & contour
 Even though inlet is large, the shape of the pelvis does not
2. fetus (THE passenger) – the FETUS (the PASSENGER) is accommodate a fetal as well as the gynecoid pelvis
of appropriate size & in an advantageous position & presentation
PLATYPELLOID “FLATTENED” (OVAL)
3. uterine factors (powers of labor) – the UTERINE
 A smoothly-curved oval inlet with anteroposterior diameter is
FACTORS (powers of labor) are adequate shallow
4. a WOMAN’S psyche – the woman’s PSYCHE is preserved  A fetal head might not be able to rotate to match the curves of
so that afterward, labor can be viewed as positive experience the pelvic cavity
5. position – her POSITION is comfortable and facilitates the estimating pelvic size (pelvimetry)
labor process  2 important pelvic measurements to determine the adequacy of
Passageway / Passage (Pelvis) the pelvic size
 The route a fetus must travel from the uterus through the cervix o diagonal conjugate (Anterior-posterior diameter of
& vagina to the external perineum the inlet)
 The mother’s bony pelvis and soft tissues of the cervix, pelvic o TUBERO-ISCHIAL or BI-ISCHIAL
floor vagina and introitus
Functions: DIAMETER (Transverse diameter of the outlet)
 Support & protect the reproductive & other pelvic organs  DC (Diagonal Conjugate) is the narrowest diameter of the inlet
 Accommodation of the growing fetus & TD (Tubero-ischial Diameter) is the narrowest diameter of
the outlet (11.5cm)
 Anchorage of the pelvic support structures
Composition:  TD of pelvic cavity/inter-spinous diameter = 10cm

 Anterior & lateral portion made up of 2 innominate hip  TD of outlet/bi-ischial diameter = 11.5cm
bones divided into 3 parts (ilium, ischium, and pubis) Anteroposterior Measurements of the Inlet
 Posterior portion: sacrum, coccyx
2 DIVISIONS OF THE PELVIS:
• FALSE PELVIS – upper half which supports the uterus
during the late months of pregnancy & aids in directing the fetus
into the true pelvis for birth
• TRUE PELVIS – lower half of the pelvis; long bony,
curved canal divided into 3 parts: inlet, pelvic cavity,
outlet
LINEA TERMINALIS or BRIM – Imaginary line from the
sacral promontory to the superior border of the SP which divides the
pelvis into true & false pelvis
diagonal conjugate = 10.5-11CM
TYPES OF FEMALE PELVIC SHAPES  Measurement between the anterior surface of the sacral
GYNECOID “FEMALE” prominence (sacral promontory) and the posterior surface
(inferior margin) of the symphysis pubis
 has an inlet that is well-rounded ad has wide pubic arch
 Measured by internal examination; AP diameter
 Ideal for childbirth
OBSTETRIC conjugate = ≥ 10cm
ANDROID “MALE”
  The distance between the midpoint of the sacral promontory &
the midline of the symphysis pubis which is ascertained by
subtracting 1 to 1.5cm from the diagonal conjugate
 OC = DC – 1 to 1.5
true conjugate/conjugata vera = ≥ 11CM
 Distance between the midpoint of the sacral promontory and the
upper or superior margin of the symphysis pubis
Measurement of the Transverse Diameter of the Outlet

 FONTANELLES – Membrane-covered spaces found at

the juncture of the main suture line
 ANTERIOR FONTANELLE (Bregma) – at the
junction of the coronal & sagittal sutures, diamond-shaped;
closes at 18mos
 POSTERIOR FONTANELL (LAMBDA) – at the
junction of the lambdoidal & sagittal sutures, triangular and
TUBERO-ISCHIAL or BI-ISCHIAL Diameter of the smaller than the bregma; closes at 2-3mos
Outlet  VERTEX – space between the fontanelles
 Distance between the ischial tuberosities, or the transverse Diameters of the Fetal Skull
diameter of the outlet (the narrowest diameter at that level, or  Wider in the anteroposterior diameter than the transverse diameter
the one most apt to cause a misfit)
 To fit in the birth canal, the smallest diameter of the skull
 Made at the medial and lowermost aspect of the ischial (Transverse Diameter (TD)) must present to the smallest diameter
tuberosities, at the level of the anus of the pelvis
 Diameter of 11cm is considered adequate because it will allow
the widest diameter of the fetal head, or 9cm, to pass freely
through the outlet.
passenger (fetus)
The head is the body part of the fetus with the largest
diameter
 Its ability to fit depends on its structure (bones, fontanelles,
suture lines) & its alignment with the pelvis
 CRANIUM is composed of 8 bones; frontal, 2 parietal,
occipital, sphenoid, ethmoid, & 2 temporal bones
 CRANIAL SUTURES are fibrous joints connecting the
bones of the skull, allowing the bones to move & overlap
(molding), diminishing the size of the skull so that it can pass
through the birth canal • suboccipitobregmatic diameter – narrowest, about
9.5cm, from the inferior aspect of the occiput to the center of the
o SAgITTAL SUTURE – joins the 2 parietal bones anterior fontanelle.
o CORONAL SUTURE – line of juncture of the • OCCIPTOFRONTAL DIAMETER – about 12cm,
frontal bones & the 2 parietal bones measured from the bridge of the nose to the occipital prominence
o LAMBDOID SUTURE – juncture of the occipital • OCCIPITOMENTAL DIAMETER – widest (Anterior
bone & the 2 parietal bones Posterior (AP)) diameter, 13.5cm; measured from the chin to the
ANATOMY OF THE FETAL SKULL posterior fontanelle the AP diameter presented depends on the
degree of flexion of the fetal head.
• FULL FLEXION – head flexes sharply that the chin rests on
the thorax; suboccipitobregmatic diameter will be presented
• MODERATE FLEXION – occipitofrontal diameter is
presented
• POOR FLEXION – head is hyperextended; the largest
diameter, occipitomental diameter is presented
• Molding – refers to change in the shape of the fetal skull STATION – refers to the relationship of the presenting part of the
produced by the force of the uterine contractions pressing the fetus to the level of the ischial spines
vertex of the head against the not-yet-dilated cervix; the  0 station – at the level of the ischial spines; synonymous to
incompletely ossified bones will overlap making the head longer
& narrower
Engagement
1. FETAL ATTITUDE  -1 to -4 (minus stations)- presenting part is above the ischial
 The degree of flexion a fetus assumes during labor or the spines; -4 is floating
relation of the fetal parts to each other  +1 to +4 (plus stations)- presenting part is below the ischial
spines
 +3 or +4 – presenting part is at the perineum & can be seen if
the vulva is separated; Crowning; +4, head is at the outlet
3. FETAL LIE
 The relationship between the long
(CEPHALOCAUDAL) axis of the fetal body and the
long (cephalocaudal) axis of the woman’s body

a. NORMAL or good ATTITUDE – chin touches the

sternum, arms are flexed & folded on the chest, thighs flexed
onto the abdomen, calves pressed against the posterior aspect of
the thighs; present the smallest AP diameter of the skull
b. MODERATE FLEXION – chin is not touching the chest
but, in an alert, or “MILITARY POSITION”, presents the
next-widest diameter, (OCCIPITO-FRONTALIS (OP))
c. PARTIAL EXTENSION – presents the “BROW”
d. COMPLETE EXTENSION – or poor flexion, back
arched, neck extended; OM DIAMETER (Face
Presentation); in oligohydramnios or neurologic
4. FETAL PRESENTATION
abnormality (spasticity)
2. FETAL Engagement  The first body part of the fetus to enter the true pelvis and also
the first body to come out during delivery
TYPES OF FETAL PRESENTATION
CEPHALIC PRESENTATION – most frequent
 fetal head is the 1st body part that will contact the cervix
 4 types: vertex, brow, face, mentum

 The settling of the presenting part of the fetus far enough into
the pelvis to be at the level of the ISCHIAL SPINES, a
midpoint of the pelvis
 Widest part of the fetus (BIPARIETAL DIAMETER
in a cephalic presentation; the
INTERTROCHANTERIC DIAMETER in a breech
presentation) has passed through the pelvic inlet; thus,
adequate for birth.
 Engagement is assessed by vaginal &cervical examination
 Floating – if the presenting part is not yet engaged
 Dipping – presenting part is descending but has not yet
reached the ischial spines
  VERTEX PRESENTATION is the ideal because skull
bones are capable of molding for a better fit, aids in cervical
dilatation, prevents cord prolapse

 BREECH PRESENTATION – either the buttocks or

the feet are the 1st body parts that will make contact with the
cervix
 good attitude- Fetal knees are up against the umbilicus
 POOR ATTITUDE- knees are extended
3 TYPES OF BREECH:

quadrants according to mother’s left & right:

 right anterior
 left anterior
 right posterior
 left posterior
4 Parts of the fetus are chosen as landmarks to describes the
relationship of the presenting part to 1 of the pelvic quadrants
 occiput or chin
In vertex presentation, it is the
(mentum); in breech, sacrum, in a shoulder
 Complete (Good flexion)
presentation, scapula or acromion process
 Frank (Moderate flexion)
 Footling (Very poor flexion)  Composed of 3 letters: middle letter denotes feal landmark
 shoulder presentation is wherein a transverse lie, presenting (o, m, sa, a/sc)
 1st letter defines whether the presenting part points anteriorly
part is 1 of the shoulders (ACROMION PROCESS), iliac (A), posteriorly (P), or transversely (T)
crest or an elbow; caused by relaxed abdominal walls (in  fastest birth – roa or loa position
multiparity), pelvic contraction, placenta previa  labor is extended & painful – rop or lop
 compound presentation is where more than 1 body part  posterior positions are more painful because rotation of
presents
the fetal head puts pressure on the sacral nerves, causing
5. fetal position back pains
types of positions
 breech presentation (sacrum)
LSaA, LSaP, LSaT – same with Right
 face presentation (mentum)
LMA- left mentoanterior, LMP, LMT – same w/ Right
 shoulder presentation (acromion process)
LAA- left scapuloanterior, LAP, RAA, RAP
powers
 the force supplied by the fundus of the uterus and
implemented by the uterine contractions which causes
cervical dilation and then expulsion of the fetus from the
uterus.
 After full dilation of the cervix, the primary power is
supplemented by use of secondary power source (abdominal
muscles)
 It is important for women to understand that they should not
bear down with their abdominal muscles to push until the
cervix is fully dilated. This could impede the primary force
and cause fetal and cervical damage.
primary power: uterine contractions
a. Characteristics:
  Involuntary, rhythmical, regular activity of uterine  the time for checking maternal BP, FHT, delivering the fetal
musculature head in precipitate labor to prevent lacerations; the time for
 Occurs intermittently by allowing for a period of uterine
maternal sleep and relaxation during labor.
relaxation between contractions followed by uterine and
maternal rest and restoration of uteroplacental circulation e. Intensity – refers to the strength of a uterine
effecting sustained fetal oxygenation contraction during acme, can be determined by
b. Purposes: palpation
 Propel presenting part downward/forward
PALPATION - placing the hand lightly on the fundus with the
 effacement of the cervix - thinning out, pulling up, fingers spread; described as mild, moderate and strong by judging the
shortening of the cervical canal degree of indentability/depressability of the uterine wall during acme.
 dilation of the cervix – opening, widening, enlarging,  When uterine fundus is very firm and cannot be indented with
increasing in diameter of the cervical os from 0 to 10cm fingers, intensity is strong.
c. Effects of Contractions:  When fundus is difficult to indent, MODERATE.
 Increased maternal BP due to increased peripheral arteriole
pressure (check BP between contractions for accurate
 When fundus is tense but can be indented easily with fingertips,
results). MILD.
intensity is
 Myometrial contractions constrict blood vessels decreasing INTRAUTERINE CATHETER – directly measures the
uteroplacental circulation strength of contractions:
 Prolonged uterine contractions can cause fetal hypoxia
 Cervical dilation during the first stage
 At ACME: intensity ranges from 30mm to 55mmHg of
pressure
effacement – shortening & thinning of the cervical canal;
normally, it is 1 to 2 cm long but with effacement, the canal virtually
 Resting tonus average: 10mmHg
disappears. Major disadvantage: invasive and requires a ruptured bag of
primiparas – effacement occurs before dilation waters
multiparas – dilation may proceed before effacement is complete SECONDARY POWERS:
but must occur before the fetus can be safely pushed a. Maternal bearing down/pushing – readiness for
 Contractions with pushing/bearing down, expel the fetus and pushing:
the placenta during the second and third stages of labor,  Cervical dilation: 10cm; fully dilated
respectively.  Fetal station: +1; low enough to stimulate Ferguson Reflex:
 Contour Changes. The uterus gradually differentiates into 2 maternal involuntary urge to push stimulated by stretch
distinct functioning areas. The upper portion becomes receptors in the pelvic floor
thicker & active, preparing it to be able to exert strength  Correct pushing: Take a deep breath as soon as the next
necessary to expel the fetus. The lower segment becomes contraction begins, then with breath held, exert a downward
thin-walled, supple & passive, so that the fetus can be pressure as exactly as though she were straining at stool
pushed out easily.  Discourage prolonged maternal breath holding of more than
 Boundary between the 2 portions becomes marked by a 6 seconds during pushing. Support involuntary pushing,
ridge on the inner uterine surface, called the physiologic grunting, groaning, exhaling, or breath holding for less than
retraction ring 6 seconds.
 Have 4 or more pushes per contraction.
 The uterus changes from an ovoid structure to an elongated
one with a longer vertical diameter. b. Intra-abdominal pressure: another secondary power;
d. 3 Phases of Uterine Contractions as the woman pushes, intra-abdominal pressure
1. increment (crescendo) – phase of increasing or increases.
‘building up’ of a contraction; the first phase; the longest PSYCHOLOGICAL RESPONSE OF THE MOTHER
phase 1. A pregnant woman’s general behavior and
2. acme (apex) – height or peak of a uterine contraction influences upon her also affect labor progress.
3. decrement (decrescendo) – the phase of decreasing Some factors make labor a meaningful, positive or
contraction, “letting up”; the last or end phase negative event:
measuring contractions a. CULTURAL INFLUENCES – how a society views
childbirth
duration – period from the beginning of increment to the
completion of decrement of the same contraction; expressed in b. EXECTATIONS AND GOALS – for the labor
seconds; the maximum normal duration is 90 seconds in the transition process; whether realistic, achievable, or otherwise
phase c. FEEDBACK FORM OTHER PEOPLE –
FREQUENCY – period of time from the beginning of 1 participating in the labor process.
contraction to the beginning of the next contraction; expressed in 2. Pregnant woman’s psychologic responses to
“every ___ minutes” uterine contractions
  Fear and anxiety affect labor progress. Woman who is mechanisms (cardinal movements of
relaxed, aware of, and participating in the birth process
usually has a shorter, less intense labor. labor)
3. Other factors that affect the psychological  Involves a number of different position changes to keep the
response of the mother include: smallest diameter of the fetal head (in cephalic presentation)
a. Childbirth preparation process (classes) – always presenting to the smallest diameters of the birth
decreased need for analgesics in labor canal
b. Support System
 The husband’s presence - during labor results to
less anxiety, less emotional tension, less pain
perception
 The attending nurse -provide a supporting and
caring environment: respect the client’s/family’s needs
and attitudes and provide therapeutic communication
4. Anticipation of pain can increase emotional
tension leading to increased pain perception.
5. Physiologic basis for discomfort during labor
a. 1st stage: dilation of the cervix, pain from the uterus
referred to pain to lower abdominal wall and the areas over
the lower lumbar region and sacrum: lumbosacral pain
radiating to the abdomen
b. 2nd stage: hypoxia of the uterine muscles during
contraction
c. Stretching of the lower uterine segment causing pressure on
adjacent structures
POSITION OF THE PARTURIENT
1. First Stage of Labor
a. Left Lateral Recumbent (LLR) or Left side-lying
position – most comfortable and best for fetal well-being as
this prevents SUPINE HYPOTENSION
SYNDROME (vena caval syndrome). Avoid supine
position.
b. Optimal Position – may vary and may range from sitting,
to squatting, to a semi-reclined, or to ambulating position.
 If bag of water is intact, may ambulate
 If bag of water has ruptured, ay still ambulate provided the
station is at least station 0 or + stations, to prevent cord
prolapse
A. engagement – assessed by vaginal & cervical
c. If the intravenous line, a moveable pose should be used to
allow ambulation if not contraindicated examination
d. No clear-cut best position; all have advantages and
disadvantages
e. in the choice of position in labor, consider the following
criteria:
 Maternal Physical and psychologic needs
 Fetal well-being
2. Second Stage of Labor
a. Lithotomy position: most commonly used in the 2nd stage;
favors the healthcare provider
 Ensure equal height of the stirrups
 Pad the stirrups
 Simultaneous placement of the legs on the stirrups
 Avoid any pressure on the popliteal region floating – if the presenting part is not yet engaged
dipping – presenting part is descending but has not yet reached
Lesson #13 the ischial spines
  Refers to the relationship of the presenting part of the fetus symphysis pubis (AP diameter of the fetal head is now in
to the level of the ischial spines the AP plane of the pelvis), the best relationship between the
 0 station – at the level of the ischial spines; synonymous to head & the outlet of the pelvis
D. internal rotation
engagement
 Begins at the level of the ischial spines
 -1 to -4 (Minus stations) – presenting part is above the
ischial spines; -4 is floating
 +1 to +4 (Plus stations) – presenting part is below the ischial
spines
 +3 to +4 – presenting part is at the perineum & can be seen
if the vulva is separated; crowning; +4, head is at the
outlet
B. descent
 Downward movement of the biparietal diameter of the fetal
head to the pelvic inlet
 full descent – when fetal head extrudes beyond the
dilated cervix & touches the posterior vaginal floor  Head enters the pelvis with the fetal AP diameter (SOB,
 Due to the pressure on the fetus by the uterine fundus, OM, OF) in a diagonal or transverse position because the
causing the mother to experience a pushing sensation, aided diameter at the pelvic inlet is widest from right to left
by contractions  Bring the shoulders in the best position to enter the inlet,
putting the widest diameter of the shoulders (transverse)
in line with the wide transverse diameter of the inlet
 This position also aligns the fetus in the optimum position to
continue descent through the pelvic outlet

C. flexion
 As the fetal head reaches the pelvic floor, the head bends
forward onto the chest, making the smallest diameter (SOB) E. extension
to be presented
 as the occiput is born, the back of the neck stops beneath the
pubic arch for the rest of the head
 upward resistance from the pelvic floor causes the head to
extend
 head extends & the foremost parts of the head, the face & the
chin, are born
 further descent is halted as the shoulders are too wide to pass
through the pelvic arch at this position
F. external rotation/restitution
 Almost immediately after the head is born, the head rotates
(from the AP position it assumed to enter the outlet) about 45°
back to the diagonal or transverse position of the early part of
 Flexion is aided by abdominal muscle contractions during the labor
pushing  This brings the shoulder into an AP position, best for entering
 The head flexes as it touches the pelvic floor & the occiput the outlet with the face turned facing one of the mother’s
rotates about 45° until it is superior or just below the thighs
  Anterior portion of the shoulder is born first, assisted by  It can be frightening & dramatic for the woman
downward flexion of the infant’s head  Administration of analgesic at this stage has no effect
G. expulsion on labor progress
 Once the shoulders are born, the rest of the body is born easily 3. transition stage
because of its smaller size, signifying the end of the 2nd stage  Contractions reach their peak of intensity, occurring
of labor every 2 to 3 mins with a duration of 60 to 90 secs &
Importance of determining fetal presentation & causing a maximum dilatation of 8 to 10 cm
position  If membranes have not ruptured before, they will
 cephalopelvic
Presentations other than vertex- implies rupture due to full dilatation (10 cm)
disproportion (cpd), membranes rupture early, increased  At the end of this phase, both full dilation (10 cm) &
risk for fetal anoxia & meconium staining, long labor full effacement (100% or full obliteration of the
cervix) will have occurred
 4 methods to determine presentation, position & lie:
 Woman experiences intense discomfort accompanied
o Abdominal inspection & palpation (Leopold’s by nausea & vomiting, feelings of loss of control,
maneuver), anxiety, panic, or irritability
o Vaginal examination  As the woman reaches the end at 10 cm, a new
o Auscultation of FHT sensation, the irresistible urge to push occurs.
o Sonography  Frequency 2-3 minutes; duration 60-90 seconds.
Lesson #14 B. second stage of labor/expulsive stage
 Duration 50-90 sec; frequency q 3 to 4 min; intensity is
stages of labor severe
A. first stage – divided into 3 phases: latent,  It is the period from full dilatation & cervical
active, & transitional effacement (unable to feel the cervix) to the birth of
the infant
1. latent phase – 6 to 8 hours
 With uncomplicated birth, it takes about 1 to 2 hours in
 Begins at the onset of regular contractions & ends a nullipara & minutes for multiparas
when rapid cervical dilation begins
 Contractions are mild and short (causing mild
 Contractions are severe at 3 to 4-min intervals lasting
for 50 to 90 secs but with a decreased frequency
discomfort only), lasting from 20 to 40 seconds
 The pattern changes to an overwhelming,
 Cervical effacement begins
uncontrollable urge to push or bear down with each
 Cervix dilates from 0 to 3cm contraction as if to move her bowels
 This stage lasts about 6 hours in a nullipara & 4.5 Ferguson reflex – the urge to bear down as the
hours in a multipara presenting part presses on the stretch receptors on the pelvic
 Prolonged latent phase may be due to: non-ripe floor causing release of oxytocin
cervix, analgesia, CPD  combination of contractions & the cardinal
 Encourage walking and making preparations for movements of labor help expel the fetus
birth, frequent emptying of the bladder, chest  As the fetal head touches the internal side of the
breathing, time the frequency and duration of
perineum, the perineum begins to bulge & appear tense
contractions
 The anus may become everted & stool may be expelled.
 Frequency q5-30 min; duration 20-40 secs; intensity
mild to moderate  The vaginal introitus opens & fetal scalp appears at the
2. active stage - 3 to 6 hours opening of the vagina

 Cervical dilatation is more rapid increasing from 4 to  At first, the opening is slit-like, then becomes oval then
circular.
7 cm
 Contractions are stronger, lasting from 40 to 60secs,
 The circle enlarges & this is called crowning
occurring approximately every 3 to 5 mins  ritgen’s maneuver
 Active phase lasts about 3 hours in a nullipara & 2  Episiotomy may be done
hours in a multipara C. third stage – 3 to 5 mins up to 1 hours
 Frequency is 3 to 5 min.; duration 40-60 secs;  Also called placental stage
intensity moderate
 It begins with the birth of the infant & ends with the
 Show (vaginal secretions) & perhaps rupture of the delivery of the placenta
membranes occur at this time
 2 separate phases occur:
 Contractions are very strong, lasts longer, & begin to
cause discomfort  placental separation
  placental expulsion • commonly, iv oxytocin (Pitocin) or im
 After birth of the infant, the placenta is palpated as a methylergonovine (methergine) is given to
firm, round mass just below the level of the umbilicus. increase contractions & minimize bleeding
 After a few minutes of rest, contractions begin again & D. fourth stage of labor
the placenta assumes a discoid shape and retains this • Lasts from 1 to 4 hours after birth & initiates postpartum
shape until it has separated, about 5 minutes up to 1 hour period
after the birth of the infant. • stage of recovery & bonding
placental separation • Nursing care:
- Active bleeding on the maternal surface o Monitor VS q 15 mins. for 1 hour
o Offer emotional support
of the placenta begins with separation;
o Perineal care
the bleeding helps push it away from o Offer regular diet as soon as she requests for food
the attachment site • Encourage full ambulation as soon as possible
- As separation is completed, the placenta o Comfort measures
sinks to the lower uterine segment or o perineum for reeda (redness, edema, ecchymosis,
discharges, approximation)
the upper vagina o Observe for complications: hemorrhage, bladder
signs of placental separation: distention, thrombosis
- Lengthening of the umbilical cord
- Sudden gush of vaginal blood
o Encourage voiding because a full bladder interferes
with contractions
- Change in the shape of the uterus; globular (calkin’s
sign) – 1st sign II. maternal and fetal responses to labor
- Firm contraction of the uterus A. physiologic effects of labor on a woman
- Appearance of the placenta at the vaginal opening 1. cardiovascular system
placental expulsion a. cardiac output - contractions decrease blood flow to
- After separation, the placenta is delivered either by the the uterus & increases blood in maternal circulation
natural bearing-down effort of the mother or by gentle increasing peripheral resistance (↑ BP, ↑Cardiac output
pressure on the contracted uterine fundus by the by 40% to 50%)
physician or nurse (crede’s maneuver) - blood loss with birth (300-500ml) compensated by
increase in blood volume during pregnancy
- Never apply pressure on a postpartal uterus in anon-
b. Blood pressure rises by an average of 15 mmHg with
contracted state because it may cause the uterus to evert
every contraction
& hemorrhage
- If it does not deliver spontaneously, it can be removed 2. hematopoietic system
manually  leukocytosis - sharp increase in circulating WBC’s
- After delivery, inspect the placenta to make sure it is due to stress and exertion
intact & normal in weight & appearance (15-28  At end of labor, 25,000 to 30,000 cells/mm
cotyledons) 3. respiratory system
- With the delivery of the placenta, the 3rd stage is over.
 ↑RR to supply enough O2
2 types of placental presentation
 Observe appropriate breathing patterns to prevent
Schultze presentation (80%) hyperventilation
• If the placenta separates first at its center & lastly at its 4. temperature regulation
edges, it will fold on itself like an umbrella & present
with the fetal surface, appearing shiny & glistening
 Slight elevation by 1°F
from the fetal membranes  diaphoresis occurs to prevent excessive warming
Duncan placenta 5. fluid balance
• If the placenta separates with the MATERNAL  Increase in RR and diaphoresis leads to insensible water
loss
SIDE (raw, red, & irregular with the cotyledons B. psychological responses of a woman to labor
showing)
• shiny Schultze, dirty Duncan  pain – reduces her ability to cope
• Normal blood loss of placental separation= 300 to 500  fear – lack of control and fear of the outcome
ml until the uterus contracts with enough force to seal  cultural influences – adapt care to woman’s specific
the blood collection spaces circumstances
III. danger signs of labor
A. maternal danger signs:
 1. high or low bp - systolic pressure >140 mm Hg, diastolic • wants to talk about her pregnancy, labor
pressure >90 mm Hg or increase of 30 mm Hg may be a sign and birth
of PIH
- sudden drop in BP may be the 1st sign of intrauterine • Touches & explores her baby
bleeding • Encourage her to talk about the birth to
2. abnormal pulse (pr = 70-80bpm) - >100 bpm may be help her integrate it into her life
a sign of hemorrhage
experience
3. inadequate or prolonged contractions - uterine
exhaustion B. TAKING-HOLD PHASE
4. pathologic retraction rings - indentation across a • 3rd to the 10th day
woman’s abdomen where the upper and lower segments join, • less dependent, take a strong interest in
may be a sign of extreme uterine stress and possible
impending rupture the care of her child and make her own
5. abnormal lower abdominal contour - with a full decisions but still feels insecure about
bladder, a round bulge on the lower abdomen may appear her mothering skills
- danger sign for 2 reasons: bladder may be injured • give guidance and demonstrations on
due to pressure; full bladder may prevent fetal head
descent how to care for her child
- void every 2 hrs. during labor C. LETTING-GO PHASE
6. increasing apprehension- O2 deprivation or internal • 10 days to 6 weeks
hemorrhage
• woman redefines her new role &
B. fetal danger signs
motherhood functions are established
1. high or low fetal heart rate - >160bmp (fetal
tachycardia), <110bmp (fetal bradycardia), decelerations may • gives up her fantasized image of her
be a sign of fetal distress child and accepts her child as a unique
2. meconium staining person
- Green color of AF due to loss of sphincter control may be
due to fetal hypoxia DEVELOPMENTAL OF PARENTAL LOVE
3. hyperactivity -sign of hypoxia & POSITIVE FAMILY RELATIONSHIPS
4. oxygen saturation (40% to 70%) - assessed by a • EN FACE POSITION – looking directly
catheter inserted next to the cheek (<40% is low); plus, at her newborn’s face with direct eye
acidosis (pH <7.2) suggests fetus is being compromised
contact
Lesson #15 • ENGROSSMENT - fathers staring at the
nursing care of a postpartal family NB for long periods of time
• COMPLETE ROOMING-IN - mother and
POSTPARTAL child are together 24h a day
PERIOD/PUERPERIUM • PARTIAL ROOMING-IN - infant
 Lat. PUER, “CHILD”, PARERE “TO remains in the woman’s room most of the
BRING FORTH” time
 6-week period after childbirth • SIBLING PREPARATION
 retrogressive (involution of the uterus & POSTPARTUM BLUES/BABY BLUES
vagina) and progressive (production of milk  2nd, 3rd postpartal day or within the 1st 2
for lactation) weeks
 FOURTH TRIMESTER OF PREGNANCY  mood swings, anger, tearfulness, feeling
I. PSYCHOLOGICAL CHANGES OF THE let-down, anorexia, insomnia,
POSTPARTAL PERIOD overwhelming sadness, feeling of
A.TAKING-IN PHASE inadequacy, mood lability
• 1st 2 to 3 days postpartum  related to hormonal changes (sudden
• passive and dependent decrease in E/P), fatigue & psychological
• preoccupied with her own needs stress related to infant dependency
  Anticipatory guidance, individualized • Complete expulsion of placenta &
support, chance to verbalize are necessary membranes
 resolves spontaneously • Factors that slow involution
II. REPRODUCTVE SYSTEM CHANGES • Prolonged labor & difficult delivery
A. UTERUS • Anesthesia
2 PROCESSES: • Grand multiparity
- Area where the placenta was implanted is • Retained placental fragments
sealed off to prevent bleeding • Full urinary bladder
- Uterus is reduced to its approximate • Infection
pregestational size • Overdistention of the uterus
INVOLUTION - reduction in size of the LOCHIA
uterus after delivery to prepregnant size • should not contain large clots
caused by uterine contractions • Total volume is 240 to 270 ml, gradually
• Immediately after birth, the uterus weighs decreasing daily; increased by exertion or
about 1,000g; after a week, 50g; after breast-feeding
involution is complete (6 weeks), 50g • Unexplained increase in amount or
FUNDUS - the top portion of the uterus; an reappearance of lochia rubra is abnormal
indicator of involution TYPES OF LOCHIA
• after delivery, fundus is palpated halfway LOCHIA RUBRA - Dark red, bloody;
between the umbilicus & symphysis fleshy, musty, stale odor that is non-
pubis, at midline or slightly to the right. offensive; may have tiny clots/ 1 to 3 days/
• 1 hour after, fundus will rise to the level Blood, mucus, fragments of decidua,
of the umbilicus & remain there for 24 epithelial cells, WBC’s, fetal meconium,
hours. From then on, it decreases 1 lanugo, vernix caseosa
fingerbreadth per day (1 cm). LOCHIA SEROSA - Pink or brownish;
• 1st postpartal day,1 fingerbreadth below watery; odorless/ 4 to 10 days/ Serum,
the umbilicus; on 2nd day, 2 RBC’s shreds of decidua, WBC’s, cervical
fingerbreadths below the umbilicus, and mucus, bacteria
so on. LOCHIA ALBA - Yellow to white; may
• By the 9th or 10th day, it can no longer be have slightly stale odor/ 11 to 21 days, my
palpated persist for 6 weeks in lactating women/
• A well-contracted uterus feels firm, like a WBC’s. decidual cells, epithelial cells, fat
grapefruit in size & tenseness; if it is cervical mucus, cholesterol, bacteria
boggy (soft & flabby), it is not contracted B. CERVIX
AFTERPAINS - uterine cramps similar to • Soft, irregular & edematous; may appear
menstrual cramps caused by intermittent bruised with multiple small lacerations
uterine contractions after delivery; more • Both internal & external os are open
painful in breastfeeding & multiparous • By the end of 1 week, the external os has
women narrowed to the size of a pencil opening
Factors that enhance involution (may admit 1 fingertip) and it will be
• Uncomplicated labor & delivery firm once again
• Breastfeeding • The internal os closes as before but the
• Early ambulation external os remains slightly open and slit-
like or stellate (star shaped)
 C. VAGINA • Bradycardia of 50 to 70 bpm is common
• Soft, edematous, with regular diameter & in the 1st 6 to 10 days; tachycardia is
multiple small lacerations related to blood loss, temperature
• Low E levels postpartum lead to elevation or difficult, prolonged birth
decreased vaginal lubrication & • Fibrinogen remains increased for 1
vasocongestion for 6 to 10 weeks, which week increasing the risk for
can result in painful intercourse thrombophlebitis
• KEGEL’s exercises will improve the • WBC count is up to 30,000/mm3
strength & tone of the vagina especially if the labor is prolonged or
III. SYSTEMATIC CHANGES difficult; aids healing & prevents
A. ABDOMINAL WALL infection
• Soft & flabby with decreased muscle tone • Varicosities will recede but won’t
• DIASTASIS RECTI - may improve disappear
depending on the physical condition, • Hemoglobin returns to normal in 2 to 6
number of pregnancies, type & amount of weeks
exercise E. GASTROINTESTINAL SYSTEM
B. HORMONAL SYSTEM • Hunger Hunger and thirst are common
• HCG & HPL are almost negligible by 24 following birth
hours by week 1, progestin, estrone & • Risk for constipation increases due to
estradiol are at pre- pregnancy levels decreased peristalsis, use of analgesics,
• FSH is low for about 12 days & will dehydration, decreased mobility during
begin to rise and initiate a new menstrual labor, & fear of pain from having a
cycle bowel movement
• Menstruation usually resumes in 7 to 9 • Risk for hemorrhoids increases because
weeks in non-lactating women (90% in of pushing during the 2nd stage of labor
12 weeks); 1st cycle is usually IV. EFFECTS OF RETROGERESSIVE
anovulatory CHANGES
• Return of ovulation varies from 2 to 18 • Exhaustion due to pregnancy, labor &
months delivery
C. URINARY SYSTEM • Weight loss (19lbs from delivery to the 5th
• On palpation, a full bladder is felt as a day postpartum/ initially due to diuresis,
firm hard area just above the symphysis influenced by breastfeeding, exercise,
pubis nutrition
• Postnatal diuresis/Diaphoresis of 2 to 3 L V.VITAL SIGN CHANGES
increases the output in the 1st 12 to 24 TEMPERATURE
hours & accounts for a 5-pound weight • Slight increase during 1st 24 hours due to
loss dehydration; relieved by adequate fluid
D. CIRCULATORY SYSTEM intake
• Blood Volume returns to normal levels • Any woman whose oral temperature rises
by within 2 weeks, eliminated by above 100.4°F (38°C) excluding the 1st 24
diuresis hours is considered febrile
• 1st 48 hours are the time of greatest risk PULSE
for complications for clients with heart • Normal postpartal range is 50 to 80 bpm
disease
 • PR is usually slightly lower than normal & • She may ovulate before menstruation
will return to normal levels at the end of occurs
the week NURSING CARE OF A WOMAN & FAMILY
• A rapid & thready pulse indicates DURING THE 1ST 24 HOURS AFTER BIRTH
hemorrhage POSTPARTUM ASSESSMENT
• Pulse > 100 bpm should be reported to the General Considerations
healthcare provider 1. Evaluate prenatal & intrapartal history for
BLOOD PRESSURE complications
• Assess for orthostatic hypotension 2. Provide privacy & encourage client to void
• Monitor if woman has history of prior to assessment
preeclampsia 3. Position client in bed with head flat for
RESPIRATIONS accurate findings
• Normal range is 16 to 24 breaths per 4. Proceed in a head-to-toe direction
minute 5. Vital Signs
VI. PROGRESSIVE CHANGES 6. Monitor breath sounds & practice deep
LACTATION breathing & coughing exercises
• Lactation or formation of breastmilk Assessment
begins in a postpartal woman whether or 1. BREASTS
not she plans to breastfeed  Determine if bottle feeding or breast
• Breast milk forms in response to decrease feeding
in E/P levels following delivery of the  Palpate for engorgement or tenderness
placenta (which stimulates Prolactin  Inspect the nipples for redness, cracks &
release) erectility if nursing
• Nipple stimulation leads to release of 2. UTERUS
OXYTOCIN from the pituitary gland; this  Gently place the non-dominant hand on
stimulates the release of PROLACTIN the lower uterine segment just above the
from the pituitary gland which causes symphysis pubis; the dominant hand
production of milk & the let-down reflex, palpates the fundus
release of milk by the contractions of the  Palpation should not cause pain
alveoli of the breasts
• PRIMARY ENGORGEMENT - 3rd or 4th  Determine uterine firmness, height of the
day as the supply of blood & lymph in the fundus, & ascertain the position of the
breast is increased & transitional milk is fundus in relation to the midline of the
produced; fades as effectivesucking and abdomen
emptying begins
RETURN OF MENSTRUAL FLOW
 If the uterus is boggy, massage gently
• With delivery of the placenta, E/P levels
using a gently, rotating motion to induce
decrease leading to ovulation
contraction; administer oxytocin as
• Not breastfeeding - menstrual flow returns
ordered
in 6 to 8 weeks
• Breastfeeding - menstrual flow returns in 3
 The fundal location must descend 1 cm
to 4 mos (LACTATIONAL
each postpartal day
AMENORRHEA) or in some, during the
entire lactation period
  Inspect any abdominal incisions, CS  Assess for postpartum blues
delivery, or tubal ligation, for REEDA: 9. BONDING
redness, edema, ecchymosis, discharge,  Describe how the parents interact with the
and approximation of the skin edges infant

3. BLADDER IMPLEMENTATION
 The client should void within 6 to 8 hours 1. PREVENT HEMORRHAGE
after delivery; catheterization may be  Assess for risk factors
necessary if delayed & bladder is  Keep bladder empty
distended  Gently massage fundus, if boggy; teach
 Assess frequency, burning or urgency, self-massage of uterus
which could indicate UTI  Administer OXYTOCIC medications if
 Evaluate the ability to completely empty ordered; oxytocin (Pitocin),
the bladder methylergonovine maleate (Methergine),
 Palpate for bladder distention, if unable to ergonovine maleate (Ergotrate)
vid or complete emptying is in question  Monitor for side effects of oxytocics;
4. BOWEL hypotension with rapid IV bolus of
 Assess for passage of flatus\ Pitocin, hypertension with Methergine &
 Inspect for signs of distention Ergotrate
 Auscultate for bowel sounds in all 4 2. PROVIDE COMFORT
quadrants for postoperative patients  Apply ice to perineum for 20 mins on/10
5. EPISIOTOMY OR PERINEAL mins off for 1st 24 hours
LACERATIONS  Encourage Sitz bath, warm or cool, TID &
 Inspect the perineum for REEDA PRN after the 1st 12 to 24 hours
 Episiotomy is usually 1 to 2 in long  Teach client perineal care after every
 Inspect for hemorrhoids elimination
6.. LOCHIA  Teach client to tighten buttocks, then sit
 Inspect type, quantity, odor & color and relax muscles
 Correlate findings with expected  Apply topical anesthetics or witch hazel
characteristics of bleeding compresses
 CS- delivered women may have less lochia  Monitor for side effects of morphine
7. HOMAN’S SIGN epidural: late- onset respiratory depression
 Pain in the calf upon dorsiflexion of the (8 to 12 hours),
foot is a positive sign & may indicate 3. PROMOTE BOWEL ELIMINATION
thrombophlebitis  Encourage early & frequent ambulation
 Inspect for pedal edema, redness, or  Encourage increased fluids & fiber
warmth; if abnormal changes are present,  Administer stool softeners; suppositories
assess pedal pulse are contraindicated is client has a 3rd- or
8. EMOTIONAL STATUS 4th-degree perineal laceration involving
 Assess if the client’s emotions are the rectum
appropriate for the situation  Teach client to avoid straining; normal
 Determine the client’s phase of postpartal bowel patterns return in 2 to 3 weeks
psychological adjustment 4. URINARY ELIMINATION
  Encourage voiding every 2 to 3 hrs even if  Increases lochia indicates overexertion;
no urge is felt modify exercise plan
 Catheterize, as ordered, for urinary 7. PROMOTE ADEQUATE NUTRITIONAL
retention; Foley catheter for 12 to 24 hours INTAKE- Add 500 kcal/day to pre-pregnancy
after CS diet; bottle-feedingmothers should return to pre-
5. PROMOTE SUCCESSFUL INFANT pregnancy diet
FEEDING PATTERN Fluid intake of 2 liters/day
Suppression of lactation & bottle feeding Continue prenatal vitamins & iron; iron is best
-utilize snug bra or breast binder continuously for absorbed in the presence of Vitamin C & may
5 to 7 days preventing engorgement increase constipation
-avoid heat & stimulation of breasts 8. PROMOTE PSYCHOLOGICAL WELL-
-apply ice packs for 20 min qid, if engorgement BEING
occurs  Encourage & support expression of
-encourage demand feedings q 3 to 4 hours, feelings, positive & negative, without guilt
awakening during the day & allowing to sleep at  Encourage client to recount birth
night Establishment of lactation & successful experience to be able to integrate
breast-feeding expectations & fantasies with reality
-utilize well-fitting bra for support  Provide recognition & praise for self- &
-teach breast care including no use of soap & air- infant-care activities
drying nipples after feedings 9. PROMOTE FAMILY WELL-BEING
-encourage nursing on demand q 2 to 3 hours,  Encourage rooming-in, presence of family
awakening during the day 7 allowing to sleep at members & their participation
night  Advise resumption of sexual activities
-advise mother to nurse 10 to 15 min on 1st after episiotomy has healed & lochia has
breast until the baby lets go of the 2nd; alternate stopped, about 3 weeks after delivery
the breast used first & rotate positions  Counsel the couple regarding
-suggest football hold or side-lying position for contraception before discharge
moms with CS or tubal ligation to avoid 10. PROMOTE MATERNAL SAFETY Give
discomfort RhoGAM or RhIg to Rh (-) mom not sensitized
-provide help with positioning, latching-on, & (-indirect Coomb’s test)
breaking suction when done nursing Give rubella vaccine if titer is < 1:8 (0.5 ml SC)
6. PROMOTE REST & GRADUAL RETURN and advise to avoid pregnancy for at least 3
TO ACTIVITY months
 Organize nursing care to avoid frequent Teach postpartum warning signs to be reported:
interruptions -bright red bleeding saturating > 1 pad/hr or
 Plan maternal rest periods when baby is passing of large clots
expected to sleep -temp > 100.4°F, chills, excessive pain, reddened
 Teach woman to resume activity gradually or warm areas of the breast, reddened or gaping
over 4 to 5 weeks; avoid lifting, stair- episiotomy, foul-smelling lochia
climbing & strenuous activity -inability to urinate; burning, frequency, or
 Simple postpartal exercises may be urgency
started: Kegel’s exercises, raising the chin -calf pain, tenderness, redness or swelling
to the chest, knee rolls, buttocks lifts
SESSION #18 Length
VITAL STATISTICS  Average matured female newborn is 53 cm
Weight (20.9 in); matured male newborn is 54 cm
 Weight depends on racial, nutritional, (21.3 in)
intrauterine & genetic factors Head Circumference
 Weight in relation to gestational age  Ave: 34 to 35 cm (13.5 to 14 in)
should be plotted on a standard neonatal  A mature newborn with circumference
graph <33 cm or > 37 cm should be investigated
 Birth weight increases with each  HC is measured with a tape measure
succeeding child in a family drawn across the center of the forehead &
 Average birth weight of a matured around the most prominent portion of the
female newborn 3.4 kg (7.5 lbs) and a posterior head
matured male newborn is 3.5 kg (7.7 lbs) Chest Circumference
 A newborn loses more than 5% to 10%  Chest circumference is usually 2 cm (0.75
of birth weight (6 to 10 oz) during the 1st to 1 in) less than head circumference
few days afterbirth since the newborn is VITAL SIGNS
no longer under the influence of salt and Temperature
fluid-retaining maternal hormones and  It is about 99°F (37.2°C) at birth because
diuresis begins on the 2nd to 3rd day of they have been confined in an internal
body organ; temperature falls almost
immediately because of immature
temperature-regulating mechanisms
4 Mechanisms of Heat Loss:
1. CONVECTION- flow of heat from the NB’s
body surface to cooler surrounding air; avoid
drafts such as windows and air conditioners
2. CONDUCTION- is the transfer of body heat to
a cooler solid object IN CONTACT with the
baby (e.g., placing baby on a cold surface); to
avoid heat loss, cover baby with a warmed
blanket or towel
3. RADIATION- transfer of body heat to a cooler
solid object NOT IN CONTACT with the baby
such as a cold window or air conditioner; move
infant as far from the cold surface as possible
 life, voiding and the passing of stool also 4. EVAPORATION- loss of heat through
reduces the weight. conversion of a liquid to vapor; newborn’s lose
 After the initial weight loss, the newborn heat as amniotic fluid on their skin evaporates;
has 1 day of stable weight then begins to dry newborn’s as soon as possible especially
gain weight their face & hair which will not be covered with
 Breastfed newborn regains birthweight clothing
within 10 days; formula-fed newborn  Newborn’s lose heat easily because they
within 7 days. After this, weight gain is 2 lack subcutaneous fat; also, shivering is
lbs/month rarely seen in NB’s
  Newborn’s conserve heat by constricting settles to 30 to 60 breaths per minute at
blood vessels & moving blood away from rest.
the skin  Respirations are likely to be irregular, with
 BROWN FAT, a special tissue found in short periods of apnea (without cyanosis)
mature Newborn’s, helps to conserve heat sometimes called PERIODIC
by increasing metabolism RESPIRATIONS
 Brown fat is found in the intrascapular  Breathing primarily involves the
region, thorax & perirenal area. diaphragm and abdominal muscles
 Mechanical measures to conserve heat:  Coughing & sneezing reflexes are present
drying & wrapping the newborn’s, placing at birth to clear the airway
them in a warmed crib, or drying them &  Newborns are obligate nose breathers
placing them under radiant warmers Blood Pressure
 KANGAROO CARE- placing a newborn  Blood pressure is about 80/46 mm Hg at
against the mother’s skin which helps birth; by the 10th day, it rises to 100/50
transfer heat from the mother to the mm Hg though readings are usually
newborn inaccurate
 Newborn’s temperature stabilizes at  Blood pressure cuff width must be no
98.6°F within 4 hours after birth more than 2/3 the length of the upper arm
 A newborn with a bacterial infection may or thigh
run a subnormal temperature unlike adults PHYSIOLOGIC FUNCTION
Pulse Cardiovascular System
 In utero, PR = 120 to 160 bpm;  Clamping of the umbilical cord forces the
immediately after birth, as rapid as 180 neonate to take in O2 through the lungs→
bpm; within 1 hour, the NB settles down ↓pressure in the chest promoting closure of
to sleep & the pulse rate stabilizes to an the ductus arteriosus; ↑pressure on the left
average of 120 to 140 bpm side of the heart closes the foramen ovale.
 HR is slightly irregular due to immature  Umbilical vein ductus venosus and u.
cardiac regulatory centers in the medulla arteries no longer receive blood, the blood
 Transient murmurs are common due to the within them clots & the vessels atrophy
incomplete closure of the fetal circulation within the next few weeks
shunts  Peripheral circulation remains sluggish for
 Femoral pulses may be palpated but radial the 1st 24 hours; acrocyanosis (cyanosis in
& temporal pulses are difficult to palpate the hands & feet) and cold feet are
 Absence of femoral pulses suggests common
possible coarctation of the aorta  Prolonged coagulation or prothrombin
 Heart rate is always determined by time due to low levels of Vitamin K
listening for an apical heartbeat for 1 full (necessary for synthesis of Factors II, VII
minute IX and X)
Respiration  It takes 24 hours for flora to accumulate in
 Respiratory rate in the 1st few minutes the intestines & for Vitamin K to be
after birth may be as high as 80 synthesized
breaths/min. As respirations stabilize, it
  Vitamin K (AQUAMEPHYTON) is smelling because breast milk is high in
administered into the vastus lateralis lactic acid
muscle immediately after birth  Formula-fed babies pass 2 to 3 bright
Respiratory System yellow, more odorous, stools
 Initial breath is initiated by a combination  Newborn under phototherapy light have
of cold receptors, lowered partial pressure bright green stools due to increased
of O2 (pO2), INCREASED Pco2 as high bilirubin secretions
as70 mm Hg before the 1st breath  Clay-colored (gray) stools are associated
 Within 10 minutes after birth, good with bile duct obstruction
residual volume is established  Blood-flecked stools usually indicate anal
 10 to 12 hours after birth, vital capacity is fissure
established  If mucus is mixed with stool or the stool is
Gastrointestinal System watery & loose, a milk allergy, lactose
 It is usually sterile at birth but within 24 intolerance, or some other condition is
hours, bacteria are present from airborne suspected
sources, vaginal secretions at birth,
hospital linens, or from contact with the
mother’s breast Urinary System
 Normal flora in the intestines are  The average newborn voids within 24
necessary for the synthesis of Vitamin K hours after birth; otherwise, should be
 Stomach capacity is about 60 to 90 ml examined for urethral stenosis or absent
 A newborn has limited ability to digest kidneys or ureters
starch & fat because pancreatic enzymes,  Males should void with enough force to
lipase & amylase remain deficient for the produce a small projected arc; females
1st few months should produce a steady stream.
 Newborn regurgitates easily because of an  NB kidneys do not concentrate urine well,
immature cardiac sphincter. producing light-colored & odorless urine
 Immature liver function leads to lowered  NB single voiding is only about 15 ml,
glucose & serum protein levels specific gravity ranges from 1.008 to 1.010
 MECONIUM- 1st stool of NB & is  Daily urine output for the 1st 1 or 2 days is
usually passed within 24 hours after birth; about 30 to 60 ml. 1st voiding may be pink
it is tarlike, sticky, blackish green and or dusky because of uric acid crystals
odorless formed from mucus, vernix, formed in the bladder in utero
lanugo, hormones & carbohydrates  Diapers can be weighed to determine the
accumulated in utero amount and timing of voiding
 If (-) stool passage by 24 to 48 hours, Immune System
suspect meconium ileus, imperforate anus,  Newborn’s have difficulty producing
bowel obstruction antibodies against antigens until about 2
 2nd to 3rd day, TRANSITIONAL STOOL months of age & are therefore prone to
which is green & loose, is passed; it infection. Thus, immunizations are not
resembles diarrhea given t infants younger than 2 months of
 4th day, breast-fed babies pass 3 to 4 light age
yellow stools per day which are sweet-
  Newborns are born with passive antibodies *Gag, cough, sneeze reflexes are also present to
(Ig G) from the mother that crossed the maintain a clear airway when normal swallowing
placenta (antibodies vs polio, measles, does not keep the pharynx free of obstructing
diphtheria, pertussis, chickenpox, rubella mucus
& tetanus 5. Extrusion Reflex.
 Newborns are routinely given Hepatitis B Purpose: prevents swallowing of inedible
vaccine during the 1st 12 hours after birth substances
 Any Health Care Practitioner with Herpes Stimulus: substance placed on the anterior
simplex eruptions should not care for portion of the tongues
newborns until the lesions have crusted Reaction: Newborn pushes away the substance
Neuromuscular System with the tongue
 Newborn exhibits neuromuscular function *Disappears at 4 months of age
by moving their extremities, attempting 6. Palmar Grasp Reflex
head control, strong cry, & newborn Newborn grasps an object placed in their palm by
reflexes since the nervous system is still closing their fingers on it
immature *Disappears at about 6 weeks to 3 months of age;
Newborn Reflexes: grasps meaningfully at 3 months of age
1. Blink Reflex 7. Step (Walk)-in-Place Reflex.
Purpose: to protect the eyes Newborn is held in a vertical position with their
Stimulus: shining a strong light on an eye, feet touching a hard surface will take a few,
sudden movement toward the eye quick, alternating steps.
Reaction: rapid eye closure *Disappears by 3 months; by 4 months, babies
2. Rooting Reflex. can bear a good portion of their weight
Purpose: to help the newborn find food; for unhindered by this reflex
nourishment 8. Placing Reflex.
Stimulus: cheek is brushed or stroked near the Similar to step-in-place but it is elicited by
mouth touching the anterior surface of the newborn’s
Reaction: the newborn will turn the head in the leg against a hard surface such as the edge of a
direction of the stimulus bassinet or table.
*Disappears at about the 6th week of life when The newborn makes a few quick, lifting motions,
the eyes focus steadily as if to step onto the table, because of the reflex
3. Sucking Reflex. 9. Plantar Grasp Reflex.
Purpose: to help the newborn find food When an object touches the sole of the newborn’s
Stimulus: When the newborn’s lips touch the foot at the base of the toes, the toes grasp n the
mother’s breast or a bottle same manner as the fingers do.
Reaction: the baby sucks to take in food * It disappears by 9 mos. in preparation for
*Diminishes in 6 months walking
*Disappears immediately if never stimulated (eg. 10. Tonic Neck Reflex/Boxer Reflex/Fencing
TEF); maintained by offering non-nutritive Reflex.
sucking such as a pacifier In a supine position, the head is usually turned to
4. Swallowing Reflex. 1 side; the arm & the leg on the side toward
Purpose: for nourishment which the head turns extend, and the opposite
Stimulus: food that reaches the posterior portion arm & leg contracts.
of the tongue is automatically swallowed
Purpose: stimulates eye coordination since the Stimulus: Newborn lies in a prone position &
extended arm moves in front of the face. touched along the paravertebral area by a finger
*May signify handedness Response: Newborn flexes the trunk & swing the
*Disappears on the 2nd to 3rd months of life pelvis towards the touch
11. Moro Reflex/Startle Reflex. 16. Landau Reflex.
Stimulus: loud noise or by jarring of the bassinet Stimulus: Newborn is held in a prone position
or by holding newborn in a supine position & with a hand underneath, supporting the trunk
allow the head drop backward 1 inch Response: Newborn must demonstrate some
Response: Newborn abducts & extends arms & muscle tone; may not be able to lift the head or
legs, fingers assume a “C” position; finally arch the back but must not sag into an inverted
swinging the arms into an embrace position & “U” position (poor muscle tone)
pull up the legs against the abdomen (adduction) 17. Deep tendon Reflex.
Purpose: like trying to ward off an attacker then Stimulus: patellar reflex is stimulated by tapping
covering up to protect himself the patellar tendon with the tip of the finger.
*It is strong for the 1st 8 weeks & fades by the Response: lower leg moves perceptively if the
end of the 4th or 5th month at the same time as the reflex is intact; test for spinal nerves L2 through
infant can roll away from danger L4
12. Babinski Reflex. 18. Biceps Reflex
Stimulus: the side of the sole of the foot is Stimulus: biceps reflex is stimulated by placing
stroked in an inverted “J” curve from the heel the thumb of your left hand on the tendon of the
upward bicep’s muscles on the inner surface of the
Response: Newborn fans the toes (+ Babinski elbow; tap the thumb as it rests on the tendon.
sign) Response: The tendon may be felt contracting
*In adults, the opposite response is normal rather than being observed; test for spinal nerves
(flexing of the toes) C5 & C6
*It remains positive (toes fan) until at least 3 The Senses- already developed at birth
months then replaced by the adult response HEARING.
13. Magnet Reflex. -A newborn is able to hear even in utero
Stimulus: pressure is applied to the soles of the VISION.
feet of a newborn lying in a supine position -May have been seeing light & dark in utero for
Response: Newborn pushes back against the the last few mos. of pregnancy as the as the
pressure. uterus & abdominal wall were stretched thin.
*Magnet, Crossed Extension & Trunk -demonstrates sight by blinking at a strong light
Incurvation reflexes are tests of spinal cord or following a bright light or toy a short distance
integrity. with their eyes; cannot follow past midline &
14. Crossed Extension Reflex. lose track of objects easily
Stimulus: 1 leg of newborn lying supine is -Newborn’s focus on black or white objects best
extended & the sole of the foot irritated by at a distance of 9 to 12 inches
rubbing with a sharp object such as a thumbnail -pupillary reflex or the ability to contract the
Response: Newborn raises the other leg & pupil is present from birth
extends it, as if trying to push away the hand TOUCH.
irritating the 1st leg. -well developed at birth; demonstrated by
15. Trunk Incurvation Reflex. quieting at a soothing touch & by positive rooting
& sucking reflex & by reaction to painful stimuli.
TASTE. common from immature peripheral
-Newborns has the ability to discriminate taste, circulation
since tastebuds are developed & functioning even ACROCYANOSIS- blueness of hands & feet is
before birth normal in the 1st 24 to 48 hours after birth
- In utero, the fetus will swallow amniotic fluid Central Cyanosis- or cyanosis of the trunk
more rapidly if sweetened by glucose & less if indicates decreased oxygenation
bitter flavor is added.  Suction the mouth of a newborn (if the
SMELL. newborn does not cry or cyanotic)1st
-present in newborn’s as soon as the nose is clear before the nose, because suctioning the
of mucus & amniotic fluid nose 1st may trigger a reflex gasp,
- Newborn’s turn toward their mother’s breast possibly leading to aspiration if there is
partly because of recognition of the smell of mucus in the posterior throat
breast milk & partly as a manifestation of the HYPERBILIRUBINEMIA- leads to jaundice &
rooting reflex. occurs on the 2nd to the 3rd day of life due to
PHYSIOLOGIC ADJUSTMENT TO breakdown of fetal RBC’s (PHYSIOLOGIC
EXTRAUTERINE LIFE JAUNDICE)
Periods of reactivity- periods of irregular CEPHALHEMATOMA- collection of blood
adjustment in the 1st 6 hours of life (Desmond) under the periosteum of the skull bone; also
1. 1st Period of reactivity- 1st phase lasting for causes release of Indirect Bilirubin
about 30 minutes; baby is alert & exhibits  Intestinal obstruction prevents evacuation
exploring, searching activity, often making of stool & intestinal flora breaks down bile
sounds; HR & RR are rapid into its basic components leading to
2. Next is a quiet, resting period- heart rate and release of Indirect Bilirubin; early feeding
respiratory rate are slow, the newborn typically of newborn promotes intestinal movement
sleeps for about 90 minutes. & excretion of meconium & helps prevent
3. 2nd period of reactivity- between the 2nd & Indirect Bilirubin build up.
6th weeks of life, when the baby wakes, often  Treatment for physiologic jaundice is
gagging or choking on mucus that accumulated rarely necessary except for early feeding to
in the mouth; alert & responsive to the speed passage of stool
environment.  Some breast-fed babies may have more
 Periods of reactivity indicates that the Nb difficulty converting IB because breast
is healthy & adjusting well to the milk contains PREGNANEDIOL
extrauterine life. (metabolite of progesterone) which
APPEARANCE OF A NEWBORN depresses action of glucoronyl transferase
SKIN PALLOR- usually the result of anemia caused
Color by:
 Most have a ruddy complexion due to (1) excessive blood loss when the cord was cut
increased circulation of RBCs in blood (2) Inadequate flow of blood from the cord to the
vessels & decreased subcutaneous fat infant at birth
 Pale & cyanotic- infants with poor CNS (3) fetal-maternal transfusion
control (4) low iron stores due to poor maternal nutrition
 Gray color- indicates infection (5) blood incompatibility
 Generalized mottling of the skin, bluish  HARLEQUIN SIGN- due to immature
appearance of the lips, hands & feet are circulation, a newborn lying on his or her
 side appears red on the dependent side of  Before the 1st bath, wear gloves when
the body & pale on the upper side; handling the NB to prevent exposure to
transient only & fades with change of body fluids
position, kicking or crying vigorously Lanugo
Birthmarks  Fine, downy hair that covers the shoulders,
 HEMANGIOMA- vascular tumor of the back, upper arms, forehead & ears of the
skin newborn
a. Nevus Flammeus- macular purple or dark-red  Post-mature infants rarely have lanugo
lesion (sometimes called port-wine stain) usually  It is rubbed away by the friction of
appearing on the face or thighs bedding & clothes against the skin; by 2
-those above the nose bridge tend to fade, weeks of age, it has disappeared
-can be removed by laser therapy though they Desquamation
may reappear  Within 24 h after birth, skin becomes
-Stork’s beak mark- lighter pink patches at the extremelydry especially on the palms &
nape of the neck which do not fade soles resulting to areas of peeling similar
b. Strawberry Hemangiomas- elevated areas to sunburn
formed by immature capillaries & endothelial  It usually needs no treatment
cells; some are present at birth while some appear Milia
up to 2 weeks after birth  Plugged or unopened sebaceous gland
-associated with high Estrogen levels of appearing as pinpoint white papules
pregnancy appear on the cheeks or across the bridge
-may increase in size up to 1 year of age, then of the nose
they tend to be absorbed & shrink in size; by 7
 Disappear by 2 to 4 weeks of age as the
years old, 50% to 75% have disappeared
sebaceous glands mature & drain
-hydrocortisone ointment may speed the
 Teach parents to avoid squeezing or
disappearance of the lesions
scratching to prevent infection
-surgery is rarely recommended because it may
Erythema Toxicum/ Flea-bite rash
lead to secondary infection
 Newborn rash usually appearing in the 1st
c. Cavernous hemangioma- dilated vascular to 4th day of life, some up to 2 weeks of
spaces, usually raised, resembling strawberry age.
hemangiomas but do not disappear with time  It begins with a papule, increases in
MONGOLIAN SPOTS- collections of pigment severity to become erythema by the 2nd
cells (melanocytes) that appear as slate-gray day & disappears by the 3rd day
patches across the sacrum or buttocks & possibly  It is caused by the newborn’s eosinophils
n the arms or the legs reacting to the environment as the immune
-common in Asians, S. Europeans, or Africans system matures.
-disappear by school age  It requires no treatment
Vernix Caseosa Forceps marks
 White, cream cheese-like substance that  Circular or linear contusions matching the
serves as a skin lubricant, noticeable on rim of the forceps blades n the infant’s
the skin of a newborn cheek; disappears in 1 to 2 days along with
 Yellow vernix- due to bilirubin the edema
 Green vernix- meconium staining
  Closely asses the facial nerve to determine  Fused suture lines prevent head from
any potential nerve compression expanding with growth
Skin Turgor Molding
 Newborn skin should feel resilient if the  Molding may be so extreme the head
underlying tissue s well-hydrated appears like a dunce cap but shape will be
 If a fold of the skin is grasped between the restored in a few days
thumb & fingers, it should feel elastic; Caput Succedaneum
when released, should fall back to form a  It is the edema of the scalp at the
smooth surface presenting part of the head
 Poor turgor is seen in those who suffered  The edema crosses suture lines & is
severe malnutrition in utero, those with gradually absorbed & disappears about the
difficulty sucking at birth or those with 3rd day of life & requires no treatment
metabolic disorders such as adrenogenital Cephalhematoma
syndrome  It is a collection of blood between the
HEAD periosteum of a skull bone & the bone
 Newborn’s head is 1⁄4 of the total body itself
length; in an adult, 1/8 of the total height  It is caused by the rupture of periosteal
 The fore head is large & prominent, the capillaries due to pressure at birth
chin appears to recede & quivers easily.  It usually appears 24 hours after birth
Fontanelles  The swelling is usually severe, well-
 Anterior fontanelle is found at the juncture outlined as an egg shape; may be
of the frontal & parietal bones; diamond- discolored (black & blue) because of the
shaped, measures 2 to 3 cm in width & 3 presence of coagulated blood
to 4 cm in length  It is confined to an individual bone so the
 Anterior Fontanelle is felt as a soft spot, swelling stops at the suture line
neither indented nor bulging  It sometimes takes weeks for the
 Anterior Fontanelle normally closes at 12 cephalhematoma to be reabsorbed
to 18 months of age Craniotabes
 Posterior fontanelle is found at the  It is a localized softening of the cranial
junction of the parietal bones & the bones caused by pressure of the fetal skull
occipital bone; triangular in shape & against the mother’s pelvic bone in utero
measures 1 cm in length  it is common in 1st-born infants because
 Posterior Fontanelle closes by the end of of the lower position of the fetal head in
the 2nd month the pelvis during the last 2 weeks of
Sutures pregnancy in the primiparous women
 They are the separating lines of the skull  the skull is so soft that the pressure of the
and may override during passage through examining finger can indent it; bone
the birth canal. returns to its normal shape after pressure is
 Molding subsides in 24 to 48 hours removed
 Wide separation of suture lines suggests  The condition resolves after a few months
increased ICP, hydrocephalus, subdural EYES
hemorrhage
  Lacrimal ducts are not fully mature until 3  In newborn’s whose membranes were
months of age; therefore, crying is initially ruptured >24h before birth, nuchal rigidity
tearless suggests meningitis
 Irises are gray or blue, sclera appears blue  Thymus gland will triple in size by 3 yrs
due to its thinness; eyes assume permanent of age & remains the same size till 10yo
color between 3 & 12 months of age then shrinks
 Small subconjunctival hemorrhage CHEST
sometimes appears due to pressure during  When 2 years old, the chest measurement
childbirth, appearing as a red spot on the will exceed that of the head
sclera usually in the inner aspect of the eye  WITCH’S MILK- breasts secrete a thin,
or as a red ring around the cornea watery fluid as an influence of the
 Bleeding is slight, requires no treatment & mother’s hormones but these hormones
is completely absorbed within 2 to 3 clear in about 1 week
weeks  Chest circumference is approximately 2
 Edema around the orbit remains for the 1st inches smaller than the head
2 to 3 days until the kidneys are capable of  RR- 30 to 60 breaths per minute
evacuating fluid more efficiently  SUPERNUMERARY NIPPLES- extra
 White pupil suggests congenital cataract nipples usually found below & in line with
MOUTH the normal nipple
 NB’s mouth should move evenly;  Grunting suggests respiratory distress
otherwise, check for cranial nerve injury syndrome
 EPSTEIN’S CYST- 1 or 2 small, round,  A high crowing sound on inspiration
glistening, well-circumscribed cysts on the suggests stridor or immature tracheal
palate, a result of the extra load of development
Calcium deposited in utero; require no ANOGENITAL AREA
treatment & disappear spontaneously  Anal patency is tested by gently inserting
within 1 week the tip of the little finger, gloved &
lubricated
 THRUSH- a Candida albicans infection  Anal patency is tested by gently inserting
appearing as white or gray patches on the the tip of the little finger, gloved &
tongue & sides of cheeks lubricated
 NATAL TEETH- evaluate for stability; all Male Genitalia
teeth not covered by gum membrane  The scrotum is edematous & has rugae,
should be removed because they can deeply pigmented in dark-skinned
loosen & may be aspirated newborn’s
NECK  If 1 or both testicles are missing, suspect
 It is short, chubby, with creased skin folds cryptorchidism; may be caused by
& head should rotate freely agenesis, ectopic testes (testes cannot enter
 CONGENITAL TORTICOLLIS- caused closed scrotal sac) or undescended testes
by injury to the sternocleidomastoid (vas deferens or artery is too short to allow
muscle during birth manifested by rigidity testes to descend)
of the neck  CREMASTERIC REFLEX- elicited by
stroking the internal side of the thigh
 causing the testis on that side to move up  It is normally slightly protuberant
upward (absent in NB’s < 10 days old)  If scaphoid or sunken, it suggests missing
 The penis appears small, approximately 2 abdominal contents or diaphragmatic
cm long hernia
EPISPADIAS- urethral opening is at the dorsal  Bowel sounds should be present within 1
side hour after birth
HYPOSPADIAS- urethral opening is at the  Edge of the liver is usually palpable 1 to 2
ventral side cm below the right costal margin; the
 Circumcision should not be done if spleen 1 to 2 cm below the left costal
epispadias or hypospadias is present margin
(foreskin may be used in the repair)  After cord cutting, count the cord (AVA);
Female Genitalia 1 artery is associated with a congenital
 Vulva may be swollen due to maternal heart or renal abnormality
hormones  After the 1st hour, umbilical stump begins
 PSEUDOMENSTRUATION- mucus to dry & shrink, turning brown; 2nd to 3rd
vaginal secretion, sometimes blood-tinged day, black
EARS  Stump falls off by day 6 to 10 leaving a
 Pinna tends to bend easily but strong granulating area that heals in 1 week
enough to recoil  Moist or odorous cord suggests infection;
 The level of the top part of the external ear treat to prevent septicemia
should be on a line drawn from the inner  PATENT URACHUS- a canal that
canthus to the outer canthus of the eye & connects the bladder to the umbilicus as
back across the side of the head; ears set manifested by moistness at the base of the
lower are found in infants with trisomy 18 cord caused by urine flow
& 13  Check for umbilical hernia; if < 2 cm, it
 Skin tags in front of the ear may be closes on its own by school age
associated with kidney or chromosomal  Newborn kidneys are the size of a walnut;
abnormalities or of no reason at all; may right kidney is lower than the left
be removed with ligation when the child is  ABDOMINAL REFLEX- stroke each
1-week old quadrant of the abdomen to cause the
 Preauricular dermal sinus appear as umbilicus to wink in that direction (not
pinpoint-size opening directly in front of demonstrable before the 10th day of life)
the ear; may be removed surgically when BACK
the child is near school age  Spine appears flat in the lumbar & sacral
 Test hearing by ringing a bell held 6 in areas; curves appear only after the child is
from each ear; newborn blink, stop crying, able to sit & walk
be startled in response.  SPINA BIFIDA OCCULTA or DERMAL
NOSE SINUS- pinpoint opening, dimpling or
 Test for CHOANAL ATRESIA by closing sinus tract in the skin
the mouth & compressing 1 naris at a time  NB typically assumes its position in utero
with the fingers. Note any discomfort or EXTREMITIES
distress with breathing.  Arms & legs appear short, hands are
ABDOMEN plump
  Fingernails are soft & smooth, sometimes  GROWTH- generally used to denote an
extend over the fingertips increase in physical size or
 Test upper extremities for muscle tone by QUANTITATIVE CHANGE; measured
unflexing the arm for 5 seconds. If tone is as weight and height
good, arm immediately returns to its  DEVELOPMENT- is used to indicate an
flexed position. increase in skill or ability to function (a
 When the arms are at the sides, the QUALITATIVE CHANGE); can be
fingertips should cover the proximal thigh; measured by observing a child’s ability to
unusually short arms may signify perform certain tasks (eg. How well a
ACHONDROPLASTIC DWARFISM child picks up small objects such as
 SIMIAN CREASE- a single crease on the raisins), by recording a parent’s
palm (normally 3 creases) plus unusual description of a child’s progress, or by
curvature of the little finger are associated using standardized tests such as the
with Down syndrome DENVER II
 If arm hangs limp or is unmoving, it  MATURATION is synonymous to
suggests birth injury (to a clavicle, development.
brachial or cervical plexus or fracture of a  PSYCHOSEXUAL DEVELOPMENT is a
long bone) specific type of development that refers to
 SYNDACTYLY- webbing of fingers or developing instincts or sensual pleasure
toes (FREUDIAN THEORY)
 POLYDACTYLY- extra digits  PSYCHOSOCIAL DEVELOPMENT
 Soles of the feet are covered refers to ERIKSON’S STAGES OF
approximately 2/3 by creases; if less, PERSONALITY DEVELOPMENT
suspect immaturity  MORAL DEVELOPMENT is the ability
 In a supine position, both hips can flexed to know right from wrong and to apply
& abducted (180°) that the knees touch or these to real-life situations (KOHLBERG)
nearly touch the surface of the bed  COGNITIVE DEVELOPMENT refers to
 If hip joint locks 160 to 170°, hip the ability to learn or understand from
subluxation (shallow, poorly-formed experience, to acquire and retain certain
acetabulum) is suggested knowledge, to respond to a new situation,
 Hold the infant’s leg with fingers on the and to solve problems (PIAGET’s
greater & lesser trochanters then abduct COGNITIVE DEVELOPMENT
the hip; if subluxation is present, a “clunk” THEORY)
of the femur head striking the shallow II. STAGES OF GROWTH AND
acetabulum CAN BE HEARD DEVELOPMENT
(ORTOLANI’S SIGN). 1. PRENATAL PERIOD- conception to birth
 If the hip can be felt slipping from the
socket, this is BARLOW’S SIGN

SESSION #19
I. DEFINITION OF TERMS
 Germinal- conception to 10 days gestation
  Embryonic- 10 days to 8 weeks gestation Ex. – growth in height proceeds in only 1
 Fetal- 2 months to birth sequence- from smaller to larger
2. INFANCY PERIOD- birth to 1 year - development proceeds in a predictable order
 Newborn/neonatal period- birth to 1 month (sitting before creeping then stand before walking
 Infancy- 1 month to 12 months and then proceed to running)
3. CHILDHOOD PERIOD- 1 year to 12 years 3. Different children pass through the predictable
 Toddler- 1 year to 3 years stages at different rates
 Preschool- 3 years to 6 years Ex. – some walk at 9 mos. while some at 14 mos.
(all stages have a range of time)
 Schoolage- 6 years to 10 years
4. All body systems do not develop at the same
 Puberty- 10 years to 12 years
rate
4. ADOLESCENCE- 12 years to 19 years
5. Development is cephalocaudal
 Early adolescence- 12 years to 16 years Ex. – Newborn can lift only the head when in a
 Late adolescence- 16 to 19 years prone position. By 2 mos., he can lift the head
III. RATES OF GROWTH and chest off the bed; by 4 mos., the head, chest
1. INFANCY- most RAPID period of growth & part of the abdomen; by 5 mos., can turn over;
 Birth weight doubles: 6 months by 9 mos., can crawl; by 1 yr, can stand or walk
 Birth weight triples: 12 months 6. Development proceeds from proximal to distal
2. TODDLER- slow, plateau body parts
 Trunk grows faster than other tissues Ex. – Newborn makes little use of the arms and
3. PRESCHOOLER- slow, uniform legs; by 3 to 4 mos., can support the upper body
 Trunk grows faster than other tissues; legs weight onthe forearms and can scoop up objects
also grow fast with the hand; 10 mos., pincer-like grasp to pick
4. SCHOOLER- slow, uniform growth up small objects
 Limbs grow most rapidly 7. Development proceeds from gross to refined
 Bones grow faster than muscles and skills
ligaments- tendency to fracture Ex. – 3 yo colors with a large crayon; 12-year-old
5. ADOLESCENCE- rapid growth, in spurts both can write with a fine pen
in height & weight 8. There is an optimum time for initiation of
 Trunk grows faster than other tissues experiences or learning
 Girls are ahead by 2 years in growth spurt Ex. – cannot learn tasks until nervous system is
 Growth spurt lasts for 3 years mature enough to allow that particular learning
 At age 9, boys and girls are the same in -those not given the opportunity to learn tasks at
size; at 12, girls are bigger than the boys target times may have more difficulty than the
IV. PRINCIPLES OF GROWTH AND usual child learning the task later on (child in a
DEVELOPMENT body cast at 12 mos. old) because the child has
1. Growth and development are continuous passed the time of optimal learning
processes from conception until death 9. Neonatal reflexes must be lost before
Ex. – at all times a child is growing now cells & development can proceed
learning new skills Ex. – infant cannot grasp with skill until the
- BW triples and height increase by 50% at 1 grasp reflex has faded nor stand steadily until the
year-old walking reflex hasfaded
2. Growth and development proceed in an orderly -neonatal reflexes are replaced by purposeful
sequence movements
-A great deal of skill and behavior is learned by c. INTELLIGENCE
practice o Children with high intelligence do not
V. Measurement Tools to Assess progress of generally grow faster than others but
growth and development tend to advance faster in skills
A. Chronological age: assessment of o Sometimes, the child with high
developmental tasks related to birth date intelligence falls behind in physical
B. Mental age: assessment of cognitive skills because he/she spends more time
development with books or mental games
1. measured by a variety of standardized 2. TEMPERAMENT
intelligence tests (IQ)  It is the usual reaction pattern of an
2. results from at least 2 separate testing sessions individual, or an individual’s characteristic
needed before an assessment is made manner of thinking, behaving, or reacting
3. uses toys and language based on mental rather to stimuli in the environment
than chronological age  It is an inborn characteristic set at birth
C. Denver Developmental Screening Test Reaction Patterns (Chess and Thomas)
(DDST) a. Activity Level- some are constantly on the go
1. Generalized assessment tool; measures gross while others move little and are docile
motor, fine motor, language; and personal-social b. Rhythmicity- rhythms or schedules in
development from newborn- 6 years physiologic functions; some are predictable while
2. does not measure intelligence some have erratic routines
D. Growth parameters c. Approach- refers to a child’s response on
1. Bone age: X-ray of tarsals and carpals; initial contact with a new stimulus; some are
determines degree of ossification unruffled, others demonstrate withdrawal, are
2. Growth charts: norms are expressed as fussy and react fearfully
percentile of height, weight, head circumference d. Adaptability- it is the ability to change one’s
for age; any child who crosses over multiple reaction to stimuli over time
percentile line needs further evaluation e. Intensity of Reaction- some react with their
VI. FACTORS INFLUENCING GROWTH whole being (tantrums) while some have a mild
AND DEVELOPMENT or low-intensity reaction
1. GENETICS f. Distractability- those who can easily shift
 eye color, height potential, learning style, attention to a new situation are easily managed;
temperament some cannot be distracted, stubborn, willful or
a. GENDER unwilling to compromise
o girls are usually born lighter and g. Attention Span and persistence- ability to
shorter; by pre-puberty, girls surge remain interested in a particular project or
ahead (puberty is 6 mos. to 1 yr. earlier activity; persistence means they keep trying to
than boys); by the end of puberty (14 to perform an activity even when they fail
16 yrs.), boys again tend to be taller h. Threshold of response- intensity level of
and heavier stimulation that is necessary to evoke a reaction
b. HEALTH i. Mood Quality- one who is always happy and
o Those who inherit a genetically- laughing has a positive mood quality
transmitted disease may not grow as Categories of Temperament
rapidly or develop as fully as a healthy 1. The Easy Child
child
-easy to care for” with predictable rhythmicity,  Poor maternal nutrition may limit growth
approach and adapt to new situations readily, & intelligence potential.
have a mild to moderate intensity of reaction,  Children with inadequate nutrient intake
have an overall positive mood quality; 40% to show inadequate physical growth and
50% prevents them from learning at their best
2. The Difficult Child intellectual level
- “difficult” with irregular habits, negative mood  Those who eat too many carbohydrates
quality, withdraw rather than approach new tend to be obese and develop motor skills
situations; 10% more slowly
3. Slow-To-Warm-Up Child  Nutrition influences susceptibility to
-overall, fairly inactive, respond mildly and adapt diseases and development of chronic
slowly to new situations, and have a general illness
negative mood VII. SIGNIFICANT PERSONS
3. ENVIRONMENT 1. INFANCY: MOTHER, mother-substitute or
a. SOCIOECONOMIC LEVEL primary caregiver
 Health care and nutrition are affected 2. TODDLER: PARENTS; mother and father
b. PARENT-CHILD RELATIONSHIP 3. SCHOOLER: teacher, peers of the same sex,
 Children who are loved thrive better than neighbors, classmates
those who are not 4. ADOLESCENCE: PEERS (greatest
 Quality time spent is more important than determinant/influencing factor of his behavior),
quantity models of leadership. Partners of same &
 Loss of love and care may interfere with a OPPOSITE SEX, adults other than parents are
child’s desire to eat, improve and advance idolized, sexual models
c. ORDINAL POSITION IN THE FAMILY VIII. FEARS OF CHILDREN
 The position of the child and the size of A. INFANCY: fear of STRANGERS; starts at 6
the family have some bearing on the mos when infant recognizes parents; peaks at 7-8
growth and development of the child mos
 An only child or the eldest generally B. TODDLERS: Fear of SEPARATION
excels in language development because Stages of separation anxiety:
conversations are mainly with adults 1. PROTEST- cries loudly
 Children learn by watching other children 2. DESPAIR- less active, monotonous voice
so an only child or an eldest child may not 3. DENIAL- silent, difficulty forming close
excel in other skills relationships
d. HEALTH C.PRESCHOOLER:
 Diseases from environmental sources can CASTRATION/MUTILATION
influence G&D *Illogical fears: GHOSTS, INANIMATE objects,
 RHD, decrease in hearing for infants cared DARK (universal fear of children)
for in the NICU (exposed to loud noises) D. SCHOOLER: Fear of
4. NUTRITION DISPLACEMENT/REPLACEMENT, disease &
 The quality of a child’s nutrition during DEATH (permanent separation from loved ones)
the growing years (including prenatally) E. ADOLESCENCE: Fear of losing Identity:
has a major influence on his/her health and acne, obesity, body odor, homosexuality, fear of
stature the UNKNOWN, disease and death (altered
identity); unfulfilled dreams; fears death the most
IX. FREUD’S PSYCHOANALYTIC  It stresses the importance of culture &
THEORY/PSYCHOSEXUAL THEORY society in the development of personality
(Sigmund Freud 1856-1939)  A person’s social view of himself is more
 Described adult behavior as being the important than instinctual drives in
result of instinctual drives that have a determining behavior.
primarily sexual nature (LIBIDO) from  At each stage, there is a conflict between 2
within the person and the conflicts that opposing forces. The resolution of each
develop between these instincts conflict, or accomplishment of the
(represented in the individual as ID), developmental task or that stage, allows
reality (the EGO), and society (the the individual to go on to the next phase of
SUPEREGO) development
 He described child development as a series  INFANT (TRUST VS. MISTRUST)-
of (PSYCHOSEXUAL STAGES) in infants whose needs are met as they arise,
which a child’s sexual gratification cuddled played with view the world as a
becomes focused on a body part safe place; if care in inconsistent,
 INFANT PERIOD (ORAL phase)- stage inadequate or rejecting, it fosters a basic
of ID (biologic pleasure principle); infants mistrust; this task arises again at each
suck for enjoyment or relief from tension successive stage of development
and for nourishment:  TODDLER (AUTONOMY VS. SHAME
o 0-6 mos- oral passive OR DOUBT)- autonomy builds on new
o 7-18 mos- oral aggressive (teething) motor & mental abilities; toddlers need to
 TODDLER (ANAL PHASE)- stage of the do what they are capable of doing, at their
EGO; focus on anal region as they begin own pace and time; if they are not allowed
toilet training; children find pleasure in to do things they want to do, they will
both retention and defecation doubt their ability and stop trying
o part of toddler’s self-discovery,  PRESCHOOLER (INITIATIVE VS.
exertion of independence GUILT)- it is learning how to do things on
 PRESCHOOLER (PHALLIC PHASE)- their own and not merely respond to or
stage of the SUPEREGO; masturbation is imitate the actions of others. Encourage
common, exhibitionism opportunities for motor play, answer
o OEDIPAL COMPLEX- son’s questions (intellectual initiative), do not
attachment to mother and jealousy inhibit fantasy or play activity. Those who
towards the father do not develop initiative may later have
o ELECTRA COMPLEX- daughter’s limited brainstorming and problem-solving
 SCHOOL-AGE (LATENT PHASE)- strict skills, waiting for clues or guidance from
SUPEREGO; libido is diverted into others before acting
concrete thinking  SCHOOLAGE CHILD (INDUSTRY VS.
 ADOLESCENT (GENITAL PHASE)- it is INFERIORITY)- The task is how to do
the establishment of new sexual aims and things well; success or failure in school or
the finding of new love objects community settings have a lasting impact
X. ERIKSON’S THEORY OF  ADOLESCENT (IDENTITY VS. ROLE
PSYCHOSOCIAL DEVELOPMENT- ERIK CONFUSION)- they must bring
ERIKSON (1902-1996) everything they have learned about
 themselves and integrate these different esteem continues to grow & child prepares for
images into a whole that makes sense the conflicts of adolescence
 YOUNG ADULT (INTIMACY VS. Adolescent: GENITAL Stage: adolescent
ISOLATION)-intimacy is the ability to develops sexual maturity & learns to establish
relate well with other people, not only the satisfactory relationships with the opposite sex:
opposite sex but also with one’s own sex Provide opportunities for the child to relate with
to form lasting friendships opposite sex; allow child to verbalize feelings
 MIDDLE-AGED ADULT about new relationships
(GNERATIVITY VS. STAGNATION)- ERIKSON’S STAGES
extend their concern from just themselves TRUST VS MISTRUST-learns to love & be
and their families to the community and loved; Provide primary caregiver, experiences
the world, become politically active, work that add to security like touch, soft sounds,
to solve environmental problems, provide visual stimulation
participate in far-reaching communities or AUTONOMY VS. SHAME – learns to be
world-based problems; those without independent; Provide opportunities for decision-
generativity stagnate and become self- making by offering choices of clothes to wear or
absorbed with a narrow perspective and toys; praise for ability to make decisions rather
lack ability to cope than the correctness of the decision.
 OLDER ADULT (INTEGRITY VS. INITIATIVE VS. GUILT- learns how to do
DESPAIR)- those with integrity feel good things (basic problem-solving) & that doing
about their life choices; those with despair things is desirable; Provide opportunities for
wish life would begin again so things exploring new places or activities; use clay,
could turn out differently water, finger paints
SUMMARY OF FREUD’S AND ERIKSON’S INDUSTRY VS INFERIORITY- child learns
THEORIES OF PERSONALITY how to do things well; Provide opportunities such
DEVELOPMENT as allowing child assemble & completea short
FREUD’S STAGES project so that child feels rewarded for
Infant: ORAL stage: explores the world by using accomplishment
mouth, esp the tongue: Oral stimulation using IDENTITY VS. ROLE CONFUSION- learn who
pacifiers; don’t discourage thumbsucking; they are and what kind of person they will be by
breastfeeding provides more stimulation due to adjusting to a new body image, seeking
increased effort emancipation from parents, choosing a vocation,
Toddler: ANAL Stage: learns to control urination & determining a value system; Provide
& defecation: Help achieve toilet training without opportunities to discuss feelings about events
undue emphasis on its importance; continue important to him/her. Offer support & praise for
when hospitalized decision making
Preschooler: PHALLIC Stage: learns sexual XI. PIAGET’S THEORY OF COGNITIVE
identity through awareness of genital area: DEVELOPMENT-JEAN PIAGET (1896-1980)
Accept sexual interest like fondling of genitals, 4 stages of development, within each stage are
as normal; help parents answerquestions about finer units or schemas
birth or sexual differences 1. INFANT 0 to 2 yrs (SENSORIMOTOR
School-age: LATENT Stage: child’s personality STAGE)- practical intelligence, at first through
development appears to be nonactive or dormant: their senses, using reflex behavior; later, they
Help child have positive experiences so self- learn people are entities separate from objects;
primary refers to activities related to a child’s 4. SCHOOL-AGE CHILD (CONCRETE
own body while circulatory reaction shows OPERATIONAL THOUGHT)- discover
repetition of behaviors concrete solutions to everyday problems ad
-secondary refers to activities separate from a recognize cause and effect relationships; as early
child’s body (hitting a mobile, making it move); as 7 yo
infant also learns permanence (peek-a-boo, -inductive reasoning- from specific to general
search for hidden objects, parent is the same (toy is broken; toy is made of plastic; all plastic
regardless of outfit, learn where their body stops toys break easily)
and their bed, parent or toy begin 5. ADOLESCENT (FORMAL OPERATIONAL
-final phase of infant year (coordination of THOUGHT)
secondary reactions)- exhibit goal-directed -capable of thinking in terms of possibility- what
behavior could be (ABSTRACT THOUGHT)-rather than
2. TODDLER (TERTIARY CIRCULAR being limited to what already is (CONCRETE
REACTION & INVENTION OF NEW MEANS THOUGHT)
& START OF PREOPERATIVE PERIOD) -able to use scientific reasoning
-tertiary circular reaction- use trial and error to -Understands deductive reasoning (from general
discover characteristics of objects and events to specific)- plastic toys break easily; this toy is
-invention of new means- able to think through plastic; it will break easily
actions or mentally project solutions to a problem
-preoperational thought- relearn on a conceptual
level some lessons mastered as infants; using
symbols to represent objects; draw conclusions
only from obvious facts they see (Daddy is
shaving therefore going to work just like
yesterday)
3. PRESCHOOLER
-intuitive thought (substage of preoperational
thought)-tend to look at an object and see only 1
characteristics or centering (banana is yellow,
medicine is bitter) which contributes to lack of
CONSERVATION (ability to discern truth,
though physical properties change) or
REVERSIBILITY (ability to retrace steps) as in
pouringbeads into differently-sized containers
wherein they conclude that there is a change in
the amount of beads
-role fantasy (how children would like something SESSION #20
to turn out) GROWTH AND DEVELOPMENT OF AN
-assimilation (taking in information and changing INFANT
it to fit their existing ideas) I. Physical Growth
-magical thinking- personification of nonliving A. Weight
things  During the 1st 6 months, the infant
-egocentrism- perceiving one’s thoughts are typically averages a weight gain of 2
better or more important than those of others lbs./month
  During the 2nd 6 mos., weight gain is 1  12 YEARS: with all permanent teeth
lb/month except FINAL MOLARS (27-28 teeth)
B. Height  17-21 years: complete permanent teeth: 32
 Infants increase in height during the 1st  SCHOOL AGE: to be checked for loose
year by 50% or grows from an average teeth before any surgery
birth length of 20 in to 30 in  CARE of teeth:
 Infant growth is most apparent in the trunk 1. brush & floss (with parent’s help) 2x a
during the early months; during the 2nd day
half, it becomes more apparent as 2. limit concentrated sweets
lengthening of the legs 3. if H2O is not fluorinated, supplements
C. Head Circumference can be given 0.25 to 0.5 mg/day
 HC increases rapidly reflecting rapid brain 4. Don’t allow a bottle of milk or juice to
growth. By the end of the 1st year, the bed-BOTTLE MOUTH CARIES
brain has reached 2/3 of its adult size 5. 1ST DENTAL VISIT AS SOON AS
D. Body Proportion ALL PRIMARY TEETH ARE OUT (2
 Chest circumference is less than that of the 1⁄2 years)
head by about 2 cm  PERMANENT TEETH
 Cervical, thoracic and lumbar vertebral 1. 6-7 yrs.: 4 “six-year-molars”
curves develop as infants hold up their 2. 12-13 yrs.: 4 additional molars
head, sit, and walk 3. 17-21 yrs..: 4 molars (“wisdom teeth”)
E. Body Systems II. PLAYS AND GAMES IN CHILDREN
 CV System- HR slows from 120- 160 bpm A. INFANT
to 100-120 bpm by the end of the 1st year 1. Solitary play- plays with body or toys
 Kidneys remain immature and not as 2. Toys: rattles, crib mobiles, teether, pacifier,
efficient at eliminating body wastes as in squeeze toys, musical boxes, large, cuddly toys,
the adult colorful balls
 Immune system becomes functional by at B. TODDLER
least 2 months of age 1. Parallel play- plays alone in the presence of
 The ability to adjust to cold is mature by 6 other children: no sharing
months of age 2. Toys:
a. push and pull toys (BEST)
b. Play telephone- age of language training
F. Teeth c. outlets for aggressive behavior: play hammer,
 1st baby tooth/ milk tooth/deciduous teeth drum, pots & pans, balls
(lower central incisor) erupt at 6 months of d. throwing and retrieving games (ball)
age e. building blocks: build tower of 2 blocks at 12-
18 mos.,
 12 months: have 8 teeth, lower & upper
4 blocks at 18 mos. to 2 yrs.., and 8 blocks at 2
central and lateral incisors
1⁄2 years
 24 months: 16 teeth
C. PRESCHOOLER
 2 1⁄2: with complete milk teeth- 20 teeth 1. COOPERATIVE PLAY: plays with others,
 Late preschool: eruption of 1st permanent can be with large group of boys & girls
teeth (first molars) 2. TOYS: play house, coloring books, clay,
 6 years: brags about DANCING TEETH cutting & pasting tools, superheroes, costumes,
dress-up dolls, ball (throws and catches balls at 5  Do not leave infant unattended in a tub
yrs.; rides tricycle at 3, bicycle at 7 yrs.) 6. Childproofing
D. SCHOOLER  Check for possible sources of lead (paint)
1. COMPETITIVE PLAY: plays with peers of since infants begin teething at 5 to 6
the same sex; games have rules where winning is months
desired  Remove all poisonous substances from
2. TOYS: Quiet games like reading, painting, bottom cupboards
radio listening, TV watching; table games: IV. PROMOTING NUTRITIONAL HEALTH
scrabble, chess; bicycle (at 7 yrs.); handicrafts  The best food during the 1st 12 months of
(late schoolers), school sports life (and the only food necessary for the
E. ADOLESCENCE 1st 6 months) is breast milk
1. Leisure, recreation activities: parties, outings,  Due to extremely rapid growth, high
picnics, movies, fantasy, DAYDREAMING, protein, high calorie intake is needed
telephone conversation, reading romance novels,  Breast fed infants gain less weight than
sports games, hobbies formula-fed infants
III. PROMOTING INFANT SAFETY A. Introduction of Solid food
Accidents are a leading cause of death in children
 Delaying feeding of solid foods until 4 to
from 1 month through 24 years of age
6 months prevents the kidneys from being
1. Aspiration Prevention
overwhelmed by the high solute load
 Round, cylindrical objects are more
 Extrusion reflex fades by 3 to 4 mos. In
dangerous (carrot, pea, hotdog) because it
preparation for the introduction of solid
can totally obstruct the airway
food.
 Do not prop feeding bottles
 Children < 5 should not be offered peanuts Schedule for introducing solid food
or popcorn 0 to 3 mos.
-Feeding only breast milk or formula for 1 st year
2. Fall Prevention- 2nd major cause of infant -Hold infant when feeding & never prop bottle
accidents when feeding
 Do not leave infant unattended on a raised -limit water intake to 1⁄2 oz. to 1 oz. at a time
surface -avoid use of honey or corn syrup
 Be prepared for infant to roll over at 2 -allow non-nutritive sucking
months 4 to 6 mos.
 Crib rails should be 2 3/8 inches apart, -introduce solid foods without salt or sugar &
narrow enough so a child cannot put his iron-fortified cereal, 1 food at a time
head between them -avoid use of juice or sweetened drinks
3. Car Safety -feed from a spoon only
 Infants up to 20 lbs. should be placed in a 7 to 9 mos.
rear- facing seat in the back seat because -introduce finger foods & cup when infant is able
an inflating air bag could suffocate them to sit up
4. Safety with Siblings -have infant join family at mealtimes
 Do not leave infants unattended with -allow self-feeding, with observation to prevent
children < 5 yrs. of age choking
5. Bathing & Swimming safety -offer fluids after solids
-introduce limited amounts of diluted juice in a  Choose 1 feeding a day to introduce
cup weaning
-avoid sugary desserts & soda 2. SELF-FEEDING
10 to 12 mos.  At 6 mos. of age, introduce the use of a
-offer 3 meals & healthy snacks spoon
-begin to wean from bottle & begin table foods 3. BATHING
-avoid fruit drinks & flavored milk  The frequency of bathing depends on the
-allow infant to feed self with spoon weather
B. Sequence of Introducing Solids  Some need frequent washing of the scalp
1. RICE CEREALS to prevent SEBORRHEA (cradle cap)
 Hypoallergenic, easy to digest
 Do not give it from the bottle to prevent 4. DIAPER –AREA CARE
aspiration and allow learning to eat with a  Change diapers frequently, about every 2
spoon to 4 hours; wash the skin & allow to dry
and apply ointment
2. VEGETABLES (7 mos.) 5. CARE OF TEETH
 Iron content is higher than fruits and  Use toothpaste after the tooth eruption
therefore given before fruits  Initial check-up is made at 2 or 2.5 years
3. FRUITS of age & continues at 6-month intervals
 Offered 1 month after beginning 6. SLEEP
vegetables (8 mos.)  Most require 10 to 12 hours of sleep at
 Offer a selection so infant is exposed to night and 1 or several naps during the day
different tastes & textures V. PARENTAL CONCERNS AND
4. MEAT (9 MOS) PROBLEMS RELATED TO NORMAL
 Beef & pork have more protein than INFANT DEVELOPMENT
chicken; offer them first 1. TEETHING
 meat is usually added as part of the  High fever, seizures, vomiting or diarrhea
evening meal in place of cereals and earache are NEVER normal signs of
5. EGG YOLKS (10 mos.) teething
 the yolks contain the bulk of iron in eggs  Teething rings may be refrigerated to
 may be prepared by hard-boiling then provide soothing coolness against tender
mashing; soft-boiling is not recommended gums
because Salmonella may not be killed and 2. THUMBSUCKING
thorough cooking makes it easier to digest  The sucking reflex peaks at 6 to 8 months,
 whole eggs are given at 12 mos. whereas thumb-sucking peaks at about 18
6. TEETHING FOODS (6 to 7 mos.) mos.
C. Establishing Healthy Eating Patterns and  Thumb sucking is normal, does not deform
Promoting Development in Daily Activities the jaw line as long as it stops by school
1. WEANING age.
 infant can drink from a cup at 9 mos. 3. USE of PACIFIERS
 Sucking reflex begins to diminish at 6 to 9  Parents should attempt to wean a child
mos., the right time to wean the infant from a pacifier any time after 3 mos. of
age
  Use of pacifiers has been linked to  In most infants, it disappears at 3 mos.
increased incidence of otitis media because it is easier to digest food & easier
 Be vigilant to prevent strangulation from to maintain an upright position
the strap or aspiration 9. SPITTING UP
4. HEAD BANGING  Formula-fed babies do it more often than
 It is normal if it begins during the 2nd half breastfed babies
of the 1st year through to the preschool  Spitting up (rolling down the chin) 2 to 3
period, associated with naptime or bedtime times a day is normal
and lasts under 15 minutes  Burp baby thoroughly, sit infant on an
5. SLEEP PROBLEMS infant chair for 30 mins after feeding to
For eliminating or coping with night waking: decrease spitting up
 Delay bedtime by 1 hour 10. DIAPER DERMATITIS
 Shorten afternoon naps  Diaper rash occurs if the diaper change is
 Do not respond immediately to infants at infrequent causing irritation from stools
night so they can have time to fall back to and from the ammonia in urine
sleep on their own  Change diapers frequently, apply A & D
 Provide soft toys or music to allow them to or Desitin ointment, and exposing the
play quietly alone diaper to air
6. CONSTIPATION 11. MILIARIA
 Foods with bulk such as fruits or  Prickly heat rash occurs often in warm
vegetables, apple juice or prune juice, add weather or when babies are overdressed or
more fluids sleep in overheated rooms
 If it persists, check for other possible  They appear as clusters of pinpoints,
conditions reddened papules with occasional vesicles
7. LOOSE STOOLS and pustules surrounded by erythema
 Infants with associated signs such as fever, appearing on the neck first spreading
cramping, vomiting, anorexia, decrease I upward to the ears and face and downward
voiding and weight loss must be evaluated to the trunk
8. COLIC  Bathe 2x a day during hot weather,
 Colic is a paroxysmal abdominal pain that eliminate sweating to prevent further
occurs generally in infants < 3 mos. of age eruption
 The infant cries loudly, pulls up the legs 12. BABY-BOTTLE SYNDROME
against the abdomen, face flushed, fists  Decay occurs because while an infant
clench and the abdomen become tense sleeps, liquid from the propped bottle
 The cause is unclear, maybe from continuously soaks the upper front teeth
overfeeding or swallowing too much air or and the lower back teeth (lower front teeth
the formula is hard to digest are covered by the tongue)
 Assess the feeding patterns, the diet and  Never put the baby to sleep with a bottle
bottle-feeding methods 13. OBESITY IN INFANTS
 Give small, frequent feedings, bubble  Obesity is a weight greater than the 90th to
frequently 95th percentile on a standardized
height/weight chart
  It occurs when there is an increase in the  SQUAT, “POT-BELLIED” appearance
number of fat cells due to excessive because of less well-developed abdominal
calorie intake muscles & short legs
 Formula should not be more than 32 oz A. Anthropometric Measurements
daily; add a source of fiber to the diet; 1. WEIGHT:
avoid refined sugars  Weight gain= 1.8-2.7kg (4-6 lbs.)/year
 Average weight (2yo) = 12 kg (27 lbs.)
 Birth weight X 4 at 21/2 yrs. Old
2. HEIGHT:
 increase of 3 inches/yr. (mainly in the
LEGS
 Ave height at 2 yrs. old = 34 in (50% adult
height)
3. HC (Head Circumference) = CC (Chest
Circumference) by 1 to 2 yrs old
4. CC > HC during toddler years
B. Distinct Characteristics and Traits of Toddlers
 NEGATIVISM: “NO”
 Development of EGO
 TEMPER TANTRUMS
 RITUALISM
 DAWDLING
 EGOCENTRICITY/SELFISHNESS
C. Psychosocial Development
 AUTONOMY VS SHAME & DOUBT
 PRE-CONCEPTUAL PHASE (2-4 yo)-
 animism, magical thinking, concrete,
literal
 Vague idea about GOD
 REWARD & PUNISHMENT
 DIFFERENTIATION- separate individual
 Withstand DELAYED GRATIFICATION
 TRANSITIONAL OBJECT
D. NUTRITION
 PHYSIOLOGIC ANOREXIA-picky,
fussy
 GRAZING, NIBBLING
 RITUALISTIC- use same plate, utensils
 CHOKING- avoid large, round foods
 FOOD JAGS- make food appealing, offer
SESSION #21
variety
GROWTH AND DEVELOPMENT OF A
E. Parental Concerns During the Toddler Years
TODDLER
  Toilet training  Risk for injury related to increased
 Ritualistic behavior independence outside the home
 Negativism  Delayed growth and development related
 Discipline to frequent illness
 Separation anxiety  Risk for imbalanced nutrition, more than
 Temper tantrums body requirements, related to fast food
F. Nursing Diagnoses: Toddler Growth and choices
Development  Risk for poisoning related to maturational
 Deficient knowledge related to best age of child
method of toilet training  Parental anxiety related to lack of
 Risk for injury related to impulsiveness of understanding of childhood development
toddler
 Interrupted family process related to need SESSION #22
for close supervision of 2-year-old GROWTH AND DEVELOPMENT OF A
 Readiness for enhanced family coping SCHOOL-AGE CHILD
related to parents’ ability to adjust to new BIOLOGIC DEVELOPMENT
needs of child  The school age child is a sturdy,
GROWTH AND DEVELOPMENT OF A complicated individual with the ability to
PRESCHOOL CHILD communicate, conceptualize in a limited
BIOLOGIC DEVELOPMENT way & become involved in complex social
 Average weight (3 years old) = 14.6 kg & motor behavior.
(32lbs.) o Height & weight increase is
 Average weight gain = 5 lbs./yr. SLOW& STEADY
 Average HEIGHT INCREASE= 6.75-7.5 o Proportional changes: slimmer,
cm (2.5-3 in)/yr. longer legs, varying proportion &
 PHYSICALPROPORTIONS: slender, lower center of gravity; posture
sturdy, graceful, agile, posturally-erect improves, fat diminishes & is
SOCIAL/MORAL DEVELOPMENT redistributed
 ASSOCIATIVE PLAY o UGLY DUCKLING STAGE –early
 IMAGINARY PLAYMATES years
o PREADOLESCENCE- from middle
 SEX Education at 5yo from parents
of childhood to 13yo
 Fear of the DARK; SLEEP TERRORS
o PUBERTY- 10 in girls, 12 in boys
 LYING, TELLS TALES
SOCIAL/MORAL DEVELOPMENT
 Stuttering
 LATENCY (FREUD)
EMOTIONAL DEVELOPMENT
 Oedipus and Electra complexes
 Gender roles
 Socialization
Nursing Diagnoses for Preschoolers
 Health-seeking behaviors related to
developmental expectations
  CHEATING
 STEALING/SHOPLIFTING- 7 years-old
 Early childhood stealing is best handled
without a great deal of emotion.
 Shoplifting must be taken seriously by
parents.
 Parents should set good examples
 INDUSTRY VS INFERIORITY- positive  HANDEDNESS- established at 6 years-
reinforcement old
 PEER GROUP- secret codes, rules  SPEECH DIFFICULTIES
 BEST FRIENDS  PREPARATION FOR PUBERTY
 BULLYING  SEX Education- HCP as resource person
 Not yet ready to abandon parental control;  SCHOOL STRESS
parents as ADULTS, not PALS  Violence or terrorism
 COMPETITIVE PLAY o Assure children they are safe.
 QUIET GAMES- collecting, reading, o Observe for signs of stress.
handicraft, board games, computer games, o Do not allow children or
music, sports
adolescents to view footage of
 EGO mastery through play traumatic events repeatedly.
MORAL & SPIRITUAL DEVELOPMENT o Watch news programs with
 REWARD AND PUNISHMENT children; explain the situation
 Concepts of Heaven & Hell portrayed.
 Concept of punishment to fit the crime o Prepare a family disaster plan;
COGNITIVE DEVELOPMENT designate a “rally point” to meet if
CONCRETE OPERATIONS ever separated.
 From making judgments from what they Recreational drug use
see (Perceptual Thinking) to making  Suspect if child regularly appears irritable,
judgments based on what they reason inattentive, or drowsy.
(CONCEPTUAL THINKING)  Counsel against use of steroids; highlight
 CLASSIFICATION future cardiovascular irregularities,
 ORDERING uncontrollable aggressiveness, and
 REVERSIBILITY-refers to the ability to possible cancer.
recognize that numbers or objects can be  Teach to recognize tobacco advertising
changed and returned to their original manipulation; caution against
condition. For example, during this stage, experimenting with smokeless tobacco.
a child understands that a favorite ball that  Role model excellent nonsmoking health
deflates is not gone but can be filled with behavior.
air again and put back into play PROBLEMS OF SCHOOLERS
 CONSERVATION is the concept of  STEALING/SHOPLIFTING (7years)-
things staying the same even though other  CHEATING
elements change, which is based on
 HANDEDNESS- established at 6 years
rational thinking.
old
DEVELOPMENTAL CONCERNS:
  SPEECH DIFFICULTIES POSTPUBESCENCE-1-2 yrs after puberty
 PREPARATION FOR PUBERTY 3 PHASES OF ADOLESCENCE:
 SEX Education- HCP as resource person EARLY ADOLESCENCE- 11-14 yrs old
 DRUG EXPERIMENTATION MIDDLE ADOLESCENCE- 15 to 17 yrs old
 SCHOOL STRESS LATE ADOLESCENCE- 18 to 20 yrs old
Nursing Diagnoses: School-Age Children SOCIAL DEVELOPMENT
 Health-seeking behaviors related to normal  IDENTITY VS ROLE CONFUSION
school-age growth and development  Easily influenced into forming concept of
 Readiness for enhanced parenting related self; choose ROLE MODELS & avoid
to improved family living conditions Labeling
 Anxiety related to slow growth pattern of  PEER GROUP influence
child  Vacillates between considerable maturity
 Risk for injury related to deficient parental &childlike behavior
knowledge about safety precautions for a  MOOD SWINGS
school-age child  AMBIVALENCE bw independence &
fear of responsibilities
COGNITIVE DEVELOPMENT
 ABSTRACT THINKING- no longer
restricted to the real & actual
(CONCRETE) but also considers the
possibilities
 FORMAL OPERATIONAL AGE
 Scientific reasoning
 Can imagine thinking other than their own

MORAL DEVELOPMENT
 INTERNALIZED SET OF MORAL
SESSION #23 PRINCIPLES- refers to moral code
GROWTH AND DEVELOPMENT OF AN SEXUAL MATURATION IN GIRLS
ADOLESCENT  THELARCHE- breast development (9-13
DEFINITIONS: 1⁄2)
ADOLESCENCE- begins with gradual  ADRENARCHE- pubic hair
appearance of 2ary sex characteristics at 11 to 12  MENARCHE- ist menstruation 2 yrs after
years old & ends with cessation of body growth changes (9 1⁄2 to 12 years old)
at 18 to 20 yrs old  OVULATION- 6 to 14 mos after
PUBERTY- the maturational, hormonal & MENARCHE
growth processes that occur when the
 Growth spurt
reproductive organs begin to function & the
 Widening of the hips
secondary sex characteristics begin to develop (3
stages)  Vaginal secretions increase
PREPUBESCENCE- 2 years before puberty  Axillary hair
PUBERTY- sexual maturity is achieved; SEXUAL MATURATION IN BOYS
menarche
  enlargement & thinning, reddening &
increasing looseness of scrotum (9 1⁄2-14
yo)
 Pubic hair, axillary & facial hair
 Penile enlargement
 Increasing muscularity
 Voice changes
 GYNECOMASTIA
 Growth spurt
 NOCTURNAL EMISSIONS
 SPERMATOGENESIS
PHYSICAL GROWTH
 ACNE
 APOCRINE SWEAT GLANDS active
 GROWTH SPURT- extremities & neck
first
PLAYS AND GAMES
 LEISURE/RECREATIONAL CAUSES OF INJURIES
ACTIVITIES  MOTOR VEHICULAR ACCIDENTS
 PARTIES, OUTING, PICNICS, MOVIES  SPORTS ACCIDENTS
 FANTASY & DAYDREAMING  DROWNING
 TELEPHONE CONVERSATIONS  ALCOHOL
 COMPUTER GAMES  DRUGS
 READING ROMANCE NOVELS  SUICIDE
 SPORTS  TEENAGE PREGNANCY
 HOBBIES

PROBLEMS WITH ADOLESCENTS

 Fatigue, poor posture
 ACNE VULGARIS
 SUICIDE
 DRUG EXPERIMENTATION
 ALCOHOLISM