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MATERNAL NEWBORN NURSING REVIEW OF REPRODUCTIVE A&P, FETAL CONCEPTION AND DEVELOPMENT ANTEPARTUM TERMINOLOGY ANTEPARTUM ASSESSMENT PHYSIOLOGICAL CHANGES.

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Presentation on theme: "MATERNAL NEWBORN NURSING REVIEW OF REPRODUCTIVE A&P, FETAL CONCEPTION AND DEVELOPMENT ANTEPARTUM TERMINOLOGY ANTEPARTUM ASSESSMENT PHYSIOLOGICAL CHANGES."— Presentation transcript:

1 MATERNAL NEWBORN NURSING REVIEW OF REPRODUCTIVE A&P, FETAL CONCEPTION AND DEVELOPMENT ANTEPARTUM TERMINOLOGY ANTEPARTUM ASSESSMENT PHYSIOLOGICAL CHANGES IN PREGNANCY PSYCHO-SOCIAL CHANGES IN PREGNANCY MATERNAL NUTRITION ASSESSMENT OF FETAL WELL BEING

2 MODULE 1 PART 1 REVIEW OF REPRODUCTIVE ANATOMY AND PHYSIOLOGY

3 REVIEW REPRODUCTIVE A&P, FETAL CONCEPTION & DEVELOPMENT THIS WILL NOT BE COVERED IN THIS LECTURE—BE PREPARED TO ANSWER REVIEW QUESTIONS IN CLASS THE QUIZ IN CLASS 1 WILL FOCUS ON CHANGES IN PREGNANCY AND TERMINOLOGY THE QUIZ IN CLASS 1 WILL FOCUS ON CHANGES IN PREGNANCY AND TERMINOLOGY

4 Review of Reproductive A&P External Genitals Internal Reproductive Organs Vagina Uterus Uterine corpus Cervix Uterine ligaments Fallopian Tubes Ovaries

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6 Figure 2–2 Female internal reproductive organs.

7 Figure 2–4 Structures of the uterus.

8 REVIEW OF REPRODUCTIVE A&P UTERINE LIGAMENTS – ROUND LIGAMENTS – OVARIAN LIGAMENTS – CARDINAL LIGAMENTS – INFUNDIBULOPELVIC LIGAMENT – UTEROSACRAL LIGAMENT

9 Figure 2–6 Uterine ligaments.

10 Figure 2–3b Blood supply to vagina, ovaries, uterus, and fallopian tube.

11 Figure 2–3a Blood supply to internal reproductive organs. Pelvic blood supply.

12 Figure 2–5a Uterine muscle layers. Muscle fiber placement.

13 MODULE 1 PART 2 REVIEW OF REPRODUCTIVE A & P

14 PELVIC STRUCTURE – Innominate bones ILIUM – ILIAC CREST ISCHIUM – ISCHIAL TUBEROSITY – ISCHIAL SPINES PUBIS – SYMPHYSIS PUBIS – Sacrum SACRAL PROMOTORY, SACROILIAC JOINTS – Coccyx

15 REVIEW OF REPRODUCTIVE A&P PELVIC DIVISION – TRUE PELVIS INLET PELVIC CAVITY OUTLET

16 Figure 2–8 Pelvic bones with supporting ligaments.

17 Figure 2–10a Female pelvis. False pelvis is shallow cavity above the inlet; true pelvis is deeper portion of cavity below the inlet.

18 Figure 2–11 Pelvic planes: coronal section and diameters of the bony pelvis.

19 REVIEW OF REPRODUCTIVE A&P PELVIC DIAPHRAGM – LEVATOR ANI – COCCYGEAL MUSCLES – DEEP FASCIA PELVIC FLOOR MUSCLES – LEVATOR ANI – ILLIOCOCCYGEUS – PUBOCOCCYGEUS, COCCYGEUS – PUBORECTALIS, PUBORECTALIS – PUBOVAGINALIS

20 Figure 2–9 Muscles of the pelvic floor. (The puborectalis, pubovaginalis, and coccygeal muscles cannot be seen from this view.)

21 REVIEW OF REPRODUCTIVE A&P – BREASTS NIPPLE AREOLA TUBERCLES OF MONTGOMERY LACTIFEROUS DUCTS ADIPOSE, GLANDULAR, FIBROUS TISSUE COOPER’S LIGAMENTS

22 Figure 2–12 Anatomy of the breast: sagittal view of left breast.

23 MODULE 1 PART 3 CONCEPTION

24 MATURATION OF OVARIAN FOLLICLE OVULATION CORPUS LUTEUM NEUROHUMORAL RESPONSE – HYPOTHALMUS RELEASES GONADATROPIN-RELEASING HORMONE TO PITUITARY FROM RESPONES FROM CNS – ANTERIOR PITUITARY THEN SECRETES FSH AND LH

25 FEMALE REPRODUCTIVE CYCLE – OVARIAN CYCLE FOLLICULAR PHASE LUTEAL PHASE FEMALE HORMONES – ESTROGEN – PROGESTERONE – PROSTAGLANDINS UTERINE CYCLE (MENSTRUAL)

26 Figure 2–13 Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle.

27 Figure 2–14 Various stages of development of the ovarian follicles.

28 REVIEW OF CONCEPTION AND FETAL DEVELOPMENT CELLULAR DIVISION – MITOSIS – MEIOSIS OOGENESIS SPERMATOGENESIS PRE-FERTILIZATION – CAPACIATION – ACROSOMAL REACTION – FERTILIZATION

29 PREEMBRYONIC STAGE CELLULAR MULTIPLICATION CLEAVAGE MORULA BLASTOCYST TROPHOBLAST IMPLANTATION CHANGES IN ENDOMETRIUM DECIDUA CAPSULARIS DECIDUA BASALIS DICIDUA VERA

30 Figure 3–2a Sperm penetration of an ovum. The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. Source: Scanning electron micrograph from Nilsson, L. (1990). A child is born. New York: Dell Publishing.

31 Figure 3–1b Each spermatogonium produces four haploid spermatozoa.

32 Figure 3–5 Formation of primary germ layers. A, Implantation of a 71⁄2-day blastocyst in which the cells of the embryonic disc are separated from the amnion by a fluid-filled space. The erosion of the endometrium by the syncytiotrophoblast is ongoing. B, Implantation is completed by day 9, and extraembryonic mesoderm is beginning to form a discrete layer beneath the cytotrophoblast. C, By day 16 the embryo shows all three germ layers, a yolk sac, and an allantois (an outpouching of the yolk sac that forms the structural basis of the body stalk, or umbilical cord). The cytotrophoblast and associated mesoderm have become the chorion, and chorionic villi are developing. Source: Adapted from Marieb, E. N. (1998).

33 Figure 3–4 During ovulation, the ovum leaves the ovary and enters the fallopian tube. Fertilization generally occurs in the outer third of the fallopian tube. Subsequent changes in the fertilized ovum from conception to implantation are depicted.

34 MODULE 1 PART 4 REVIEW OF CONCEPTION AND FETAL DEVELOPMENT

35 CELLULAR DIFFERENTIATION – THREE PRIMARY GERM LAYERS ECTODERM MESODERM ENDODERM EMBRYONIC MEMBRANES – AMNION – CHORION – AMNIOTIC SAC

36 REVIEW FETAL DEVELOPMENT AMNIOTIC FLUID UMBILICAL CORD PLACENTA

37 REVIEW OF FETAL DEVELOPMENT EMBRYONIC AND FETAL DEVELOPMENT – EMBRYONIC STAGE—DAY 15 T0 8 TH WEEK – FETAL STAGE—8 TH WEEK TO BIRTH

38 Figure 3–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.

39 Figure 3–7 Early development of primary embryonic membranes. At 41⁄2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed. Source: Adapted from Marieb, E. N. (1998).

40 Figure 3–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.

41 Figure 3–7 Early development of primary embryonic membranes. At 41⁄2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed. Source: Adapted from Marieb, E. N. (1998).

42 Figure 3–6 Endoderm differentiates to form the epithelial lining of the digestive and respiratory tracts and associated glands. Source: Adapted from Marieb, E. N. (1998).

43 Figure 3–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninth week. Source: Adapted from Marieb, E. N. (1998).

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45 MODULE 1 PART 5 REVIEW QUESTIONS

46 REVIEW QUESTIONS WHAT IS THE SIGNIFICANCE OF THE ENDOMETRIAL (MUCOSAL) LAYER OF THE UTERUS? THE UTERUS IS MADE UP OF WHAT TYPE OF MUSCLE? ESTROGEN IS SECRETED BY THE_______? PROGESTERONE IS SECRETED BY THE_______? WHAT IS THE FUNCTION OF FSH AND LH? DESCRIBE MEIOSIS.

47 REVIEW QUESTIONS WHERE DOES FERTILIZATION OCCUR? THE BLASTOCYST DEVELOPS INTO THE ______. THE TROPHOBLAST DEVELOPS INTO THE ____. THE PLACENTA DEVELOPS FROM THE ______. WHICH SYSTEMS/STRUCTURES DEVELOP FROM THE MESODERM LAYER?

48 NAME THREE FACTORS THAT AFFECT FETAL DEVELOPMENT. WHAT IS THE ROLE OF THE BROAD AND ROUND LIGAMENTS? WHAT IS THE UPPER PORTION OF THE UTERUS CALLED? WHATS CHANGES OCCUR IN THE FUNCTION OF THE OVARIES AT ABOUT THE TH WEEK OF PREGNANCY?

49 MODULE 1 PART 6A PHYSIOLOGICAL CHANGES IN PREGNANCY

50 PHYSIOLOGICAL CHANGES IN PREGNANCY ENDOCRINE MUSCULOSKELETEL RENAL INTEGUMENTARY RESPIRATORY GI GU REPRODUCTIVE GROWTH OF PLACENTA CARDIOVASCULAR

51 REPRODUCTIVE SYSTEM – PLACENTA – AMNION – CHORION – UMBILICAL CORD – AMNIOTIC FLUID

52 REPRODUCTIVE SYSTEM PLACENTAL FUNCTION – METABOLIC – TRANSPORT – ENDOCRINE

53 REPRODUCTIVE SYSTEM OVARIES – STOP PRODUCING OVA. CORPUS LUTEUM IS ACTIVE WEEKS INTO PREGNANCY TO PRODUCE ESTROGEN AND PROGESTERONE. THEN WHAT HAPPENS? BREASTS INCREASED VASCULARITY AND SIZE HYPERTROPHY OF MAMMARY AVEOLI BECOME MORE NODULAR; NIPPLES ENLARGE PIGMENTATION OF AREOLA; COLUSTRUM

54 REPRODUCTIVE SYSTEM – UTERUS INCREASE IN SIZE, WEIGHT, AND VOLUME CAPACITY FIBROUS TISSUE INCREASES INCREASE IN BLOOD FLOW – CERVIX GOODALL’S SIGN, CHADWICK’S SIGN DEVELOPMENT OF MUCOS PLUG

55 REPRODUCTIVE SYSTEM VAGINA – MUCOSA THICKENS – INCREASE IN SECRETIONS – LOOSENING OF CONNECTIVE TISSUE— WHY?

56 RESPIRATORY SYSTEM – O2 CONSUMPTION INCREASES – BREATHING CHANGES FROM ABDOMINAL TO THORACIC – INCREASED VACULARITY – DIAPHRAGM ELEVATES

57 CARDIOVASCULAR SYSTEM – BLOOD VOLUME INCREASES – DECREASE IN SYSTEMIC AND PULMONARY RESISTANCE IN THIRD TRIMESTER – INCREASE IN CARDIAC OUTPUT, PULSE INCREASE (10-15 BPM) Why? – SVR DECREASE IN THIRD TRIMESTER

58 MUSCULOSKELETAL SYSTEM – PELVIC JOINTS RELAX – CENTER OF GRAVITY CHANGES METABOLISM – EXTRA WATER, FAT, AND PROTEIN STORED – FATS ARE MORE COMPLETELY ABSORBED – BMR INCREASE (CAN BE UP TO 25%)

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60 MODULE 1 PART 6B PHYSIOLOGICAL CHANGES IN PREGNANCY

61 GASTRONTESTINAL – SMOOTH MUSCLE RELAXATION— RELATED TO PROGESTERONE INFLUENCE

62 RENAL – FREQUENCY – DILATATION OF KIDNEYS, URETERS ELONGATE – INCREASED GFR, CREATININE CLEARANCE AND RENAL PLASMA—FLOW-WHY? – GLYCOSURIA MAY OCCUR

63 INTEGUMENTARY – HYPERPIGMENTATION – STRIAE – CHLOASMA (MELASMA) – VASCULAR SPIDER NEVI – DECREASED HAIR GROWTH – HYPERACTIVE SWEAT AND SEBACEOUS GLANDS

64 ENDOCRINE SYSTEM – THYROID—T4 AND BMR INCREASE (25% BY TERM), TSH DECREASES THYROID—GLAND ENLARGES, INCREASED IODINE METABOLISM, INCREASED VASCULARITY – PITUITARY—FSH AND LH SUPPRESSED, SECRETION OF PROLACTIN, OXYTOCIN, AND VASOPRESSION – PANCREAS—INSULIN PRODUCTION INCREASE – TO COMPENSATE FOR PLACENTAL HORMONE INSULIN ANTAGONISTS

65 ENDOCRINE SYSTEM CONCENTRATION OF PARATHYROID HORMONE INCREASES—WHY IS THIS SIGNIFICANT? INCREASED ALDOSTERONE ADRENALS—LITTLE CHANGE

66 ENDOCRINE SYSTEM ESTROGEN LIST THREE ACTION OF ESTROGEN DURING PREGNANCY ESTROGEN IS PRIMARILY EXCRETED BY THE ______ DURING PREGNANCY

67 ENDOCRINE SYSTEM PROGESTERONE – LIST THREE ACTIONS OF PROGESTERONE DURING PREGNANCY

68 ENDOCRINE SYSTEM hCG--(HUMAN CHORIOGONADATROPIC HORMONE)--STIMULATES PROGERTERONE AND ESTROGEN TO MAINTAIN PREGNANCY hPL—(HUMAN PLACENTAL LACTOGEN)— DECREASES MATERNAL METABOLISM FOR GLUCOSE (INSULIN ANTAGONIST) PROSTGLANDINS

69 ENDOCRINE SYSTEM – RELAXIN DECREASES UTERINE CONTRACTILITY SOFTENS CERVIX SOFTENS JOINTS REMODELS COLLAGEN

70 MODULE 1 PART 7 PSYCHOLOGICAL CHANGES IN PREGNANCY

71 MOTHER’S RESPONSE TO PREGNANCY AMBIVALENCE ACCEPTANCE INTROVERSION MOOD SWINGS FEAR CHANGES IN BODY IMAGE ANTEPARTUM DEPRESSION?

72 FATHER’S RESPONSE TO PREGNANCY CONFUSED BY PARTNER’S MOOD SWINGS FEELS LEFT OUT RESENTS ATTENTION GIVEN YO THE WOMAN RESENTS CHANGES IN THEIR RELATIONSHIP NEEDS TO RESOLVE CONFLICTS ABOUT FATHERING

73 MODULE 1 PART 8 ANTEPARTUM TERMINOLOGY

74 GESTATION ANTEPARTUM INTRAPARTUM POSTPARTUM PRETERM LABOR POSTTERM LABOR

75 GRAVIDA – NULLIGRAVIDA – PRIMIGRAVIDA – MULTIGRAVIDA

76 PARA – NULLIPARA – PRIMIPARA – MULTIPARA

77 ABORTION: 4-20 WEEKS PRE-TERM: WEEKS TERM: 39 WEEKS, 1 DAY- 42 WEEKS

78 TPAL T--NUMBER OF TERM PREGNANCIES P--NUMBER OF BIRTHS AFTER 20 WEEKS A—NUMBER OF ABORTIONS L—NUMBER OF LIVING CHILDREN

79 G/TPAL EXERCISES GTPAL G31201 G20313 G52133 G20503

80 MODULE 1 PART 9A ANTEPARTUM PHYSICAL AND PSYCHO-SOCIAL ASSESSMENT

81 ANTEPARTUM PHYSICAL AND PSYCHO-SOCIAL ASSESSMENT FINDINGS RELATED TO PREGNANCY PHYSICAL ASSESSMENT ECONOMICS ENVIRONMENT SUPPORT SYSTEM FAMILY FUNCTION CLIENT PROFILE EDUCATIONAL NEEDS CULTURE RISK FACTORS

82 CULTURAL BELIEFS AND PRACTICE ASSESSMENT IN ANTEPARTUM PERIOD HOME REMEDIES NUTRITION ALTERNATIVE HEALTH CARE PROVIDERS FAMILY SUPPORT EXERCISE SPIRITUALITY

83 CULTURAL CONSIDERATIONS/ASSESSMENT IN ANTEPARTUM PERIOD VIEW OF PREGNANCY SELF CARE PRACTICES PAIN CHILDBIRTH PRACTICES CARE OF THE NEWBORN POST PARTUM

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85 SIGNS OF PREGNANCY SUBJECTIVE (PRESUMPTIVE) OBJECTIVE (PROBABLE) DIAGNOSTIC (POSITIVE)

86 DUE DATE EDD, EDC, EDB NAEGLE’S RULE—SUBTRACT 3 MONTHS FROM FIRST DAY OF LAST MENSTRUAL PERIOD AND ADD 7 DAYS EXAMPLE: LMP OCT. 12—EDB---JULY 19

87 CLIENT PROFILE CURRENT PREGNANCY PAST PREGNANCY CURRENT MEDICAL/SUGICAL HISTORY GYN HISTORY FAMILY MEDICAL HISTORY RELIGIOUS, SPIRITUAL, CULTURAL HISTORY OCCUPATIONAL HISTORY PERSONAL INFORMATION—(PSYCHOSOCIAL)

88 ANTEPARTUM RISK FACTORS FACTORS RELATED TO : ECONOMICS ENVIRONMENT CURRENT HEALTH STATUS/PRACTICES AGE NUTRITION CHILDBIRTH HISTORY SOCIAL ISSUES PYSCHOLOGICAL STATUS

89 MODULE 1 PART 9B ANTEPARTUM PHYSICAL AND PSYCHOSOCIAL ASSESSMENT

90 ANTEPARTUM PHYSICAL ASSESSMENT VSUTERUS SKINEXTERNAL GENITALS MOUTH, EARS, NECKCERVIX, VAGINA CHEST AND LUNGSANUS AND RECTUM BREASTSLAB EVALUATION HEART ABDOMEN EXTREMITIES REFLEXES SPINE

91 LAB EVALUATIONS INITIAL ANTEPARTUM VISIT SCREENING TESTS – CBC – ABO AND Rh TYPING – WBC WITH DIFFERENTIAL – FIRST TRIMESTER ANEUPLOIDY – STD SCREENING, HIV – GLUCOSE – RUBELLA TITER – HEPATITS B – SICKLE CELL – PAP SMEAR

92 PSYCHO-SOCIAL ANTEPARTUM ASSESSMENT CULTURE PSYCHOLOGIC STATUS EDUCATIONAL NEEDS SUPPORT SYSTEMS FUNCTIONING OF FAMILY ECONOMIC STATUS ENVIRONMENT

93 MATERNAL NUTRITION AVERAGE WEIGHT GAIN PATTERN OF WEIGHT GAIN NUTRITIONAL REQUIREMENTS – CALORIES – PROTEIN

94 MATERNAL NUTRITION – FAT – CARBS – VITAMINS – MINERALS CULTURAL CONSIDERATIONS

95 MATERNAL NUTRITION – VEGETARIANISM – LACTOSE DEFICIENCY – EATING DISORDERS – PICA – ADOLESCENT WHAT TEACHING WOULD YOU DO FOR THESE ALTERATIONS/ CHANGES IN NUTRITION?

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98 ANTEPARTUM ASSESSMENT FETAL DEVELOPMENT FUNDAL HEIGHT QUICKENING FETAL HEART RATE ULTRASOUND

99 Figure 7–5 Approximate height of the fundus at various weeks of pregnancy.

100 Figure 8–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundal height.

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102 MODULE 1 PART 10 ASSESSMENT OF FETAL WELL BEING

103 FETAL ACTIVITY ULTRASOUND – TRANSABDOMINAL – TRANSVAGINAL NUCAL TRANSLUCENCY TESTING (NTT) DOPPLER BLOOD FLOW STUDIES

104 AMNIOCENTESIS (AMNIOTIC FLUID ANALYSIS) – EVALUATION OF FETAL HEALTH – EVALUATION OF LUNG MATURITY CHORIONIC VILLI SAMPLING (CVS) WHAT IS THE ADVANTAGE OF THE CVS?

105 TERATOGENESIS MEDICATIONSMATERNAL: NUTRITIONVIRUS ALCOHOLRADIATION COCAINE TOBACCO HYPERTHERMIA CAFFEINE MARIJUANA

106 MODULE 1 PART 11 DANGERS/DISCOMFORTS IN PREGNANCY

107 DANGER SIGNS OF PREGNANCY VAGINAL BLEEDING LEAKAGE OF FLUID FROM VAGINA ABDOMINAL PAIN TEMP > 101 DIZZINESS, BLURRING OF VISION SEVERE HEADACHE EDEMA OF HANDS, FACE, FEET

108 DANGER SIGNS OF PREGNANCY PERSISTENT VOMITING MUSCULAR IRRITABILITY EPIGASTRIC PAIN OLIGURIA DYSURIA ABSENCE OF FETAL MOVEMENT

109 DISCOMFORTS OF PREGNANCY FIRST TRIMESTER – NAUSEA AND VOMITING – URINARY FREQUENCY – FATIGUE – BREAST TENDERNESS

110 DISCOMFORTS OF PREGNANCY – INCREASED VAGINAL DISCHARGE – NASAL STUFFINESS & EPITAXIS – PTYALISM

111 DISCOMFORTS OF PREGNANCY SECOND & THIRD TRIMESTER – HEARTBURN – ANKLE EDEMA – VARICOSE VEINS – HEMORRHOIDS

112 DISCOMFORTS OF PREGNANCY – CONSTIPATION – BACKACHE – LEG CRAMPS – FAINTNESS

113 DISCOMFORTS OF PREGNANCY – DYSPNEA – FLATULENCE – CARPAL TUNNEL SYNDROME – DIFFICULTY SLEEPING – ROUND LIGAMENT PAIN

114 DISCOMFORTS OF PREGNANCY DETERMINE WHICH SYSTEM IS RESPONSIBLE FOR EACH OF THE DISCOMFORTS OF PREGNANCY. EXPLAIN HOW THE PHYSIOLOGICAL CHANGES THAT OCCUR IN EACH SYSTEM DURING PREGNANCY CAN BE RESPONSIBLE FOR THE DISCOMFORTS. WHAT INTERVENTIONS WOULD YOU USE TO TREAT THE DISCOMFORTS? (EBP)

115 SUBSEQUENT LAB EVALUATION HEMOGLOBIN QUAD MARKER (15-20 WEEKS) INDIRECT COOMBS 50 G 1 HOUR GLUCOSE SCREEN URINALYSIS—GYCOSURIA, PROTEINURIA GROUP B STREP SCREENING (35-37 WEEKS)

116 SELF CARE PROMOTION BATHING EMPLOYMENT TRAVEL ACTIVITY, REST FETAL ACTIVITY MONITORING BREAST CARE CLOTHING BATHING

117 SELF CARE PROMOTION DENTAL CARE IMMUNIZATIONS SEXUAL ACTIVITY COMPLEMENTARY & ALTERNATIVE THERAPIES ABSTINENCE FROM ALCOHOL, TOBACCO, DRUGS PSYCHO-SOCIALSUPPORT


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