Chapter01 A Framework For Maternal and Child Nursing

UNITONE
Maternal and Child Health
Nursing Practice
CHAPTER1
A Framework for Maternal and Child Health

Nursing
Key Terms
Objectives
clinical nurse specialist
After mastering the contents of this chapter, you should be able to: evidence-based practice family
nurse practitioner fertility rate maternal and child health
nursing mortality rate neonatal nurse practitioner neonate nurse-midwife nursing research pediatric nurse
practitioner puerperium scope of practice women’s health nurse practitioner

1. Identify the goals and philosophy
of maternal and child health nursing. 2. Describe the evolution, scope,
and professional roles for nurses in maternal and child health nursing. 3. Define common statistical terms
used in the field, such as infant and maternal mortality. 4. Discuss the implications of the
common standards of maternal and child health nursing and the health goals for the nation for maternal and
child health nursing. 5. Discuss the interplay of nursing
process, evidence-based
practice, and nursing theory as they relate to the future of maternal and child health nursing practice. 6. Use
critical thinking to identify
areas of care that could benefit from additional research or application of evidence-based practice. 7. Apply
concepts of family-
centered care to maternal and child health nursing. 8. Integrate knowledge of trends in
maternal and child health care with the nursing process to achieve quality maternal and child health nursing
care.
Anna Chung is a premature neonate who must be transported to a regional center for care about 30 miles from
your local hospital. Her parents, Melissa and Robert, have many concerns. They don’t want to be so far from their
daughter, and they don’t know how they will pay for her special care. Also, Melissa, 37 years old, believes she is too
old to leave the hospital so soon after having a cesarean birth. She recalls staying in the hospital much longer after
having her first child, Micko, now 6 years old.
This chapter discusses standards and philosophies of maternal-child health care and how these standards and
philosophies affect care.
What are some health care issues evident in this scenario? How has modern cost containment changed this
scenario?
What is the nursing role here?
After you’ve studied this chapter, access the accompanying website. Read the patient scenario and answer the questions to further sharpen
your skills, grow more familiar with RN-CLEX types of questions, and reward yourself with how much you have learned.
UNIT 41 Maternal and Child Health Nursing Practice

T
he a healthy major care of adults focus childbearing of you nursing must and have practice, childrearing healthy
because children. families to have To is
have healthy children, it is important to promote the health of the childbearing woman and her family from the time
before children are born until they reach adulthood. Both preconceptual and prenatal care are essential contributions
to the health of a woman and fetus and to a family’s emotional preparation for childbearing and childrearing. As
children grow, families need continued health supervision and support. As children reach maturity and plan for their
families, a new cycle begins and new support becomes necessary. The nurse’s role in all these phases focuses on
promoting healthy growth and development of the child and family in health and in illness. Although the field of
nursing typically divides its concerns for families during childbearing and childrearing into two separate entities,
maternity care and child health care, the full scope of nursing practice in this area is not two separate entities, but
one: maternal and child health nursing (Fig. 1.1).
AB
FIGURE 1.1 Maternal and child health nursing includes care of the pregnant woman, child, and family. (A) During a
prenatal visit, a maternal child health nurse assesses that a pregnant woman’s uterus is expanding normally. (B)
During a health maintenance visit, a maternal child health nurse assesses a child’s growth and development. (©
Barbara Proud.)
GOALS AND PHILOSOPHIES OF MATERNAL AND CHILD HEALTH NURSING
The primary goal of maternal and child health nursing care can be stated simply as the promotion and mainte-
nance of optimal family health to ensure cycles of optimal childbearing and childrearing. Major philosophical
assump- tions about maternal and child health nursing are listed in Box 1.1. The goals of maternal and child health
nursing care are necessarily broad because the scope of practice is so broad. The range of practice includes
• Preconceptual health care
• Care of women during three trimesters of pregnancy and the puerperium (the 6 weeks after childbirth, sometimes
termed the fourth trimester of pregnancy)
• Care of children during the perinatal period (6 weeks before conception to 6 weeks after birth)
• Care of children from birth through adolescence
• Care in settings as varied as the birthing room, the pediatric intensive care unit, and the home
In all settings and types of care, keeping the family at the center of care delivery is an essential goal. Maternal and
BOX 1.1
Philosophy of Maternal and Child Health Nursing
• Maternal and child health nursing is family- centered; assessment data must include a family and individual
assessment.
• Maternal and child health nursing is community- centered; the health of families depends on and influences the
health of communities. • Maternal and child health nursing is research-

oriented, because research is the means whereby critical knowledge increases.
• Both nursing theory and evidence-based practice provide a foundation for nursing care.
• A maternal and child health nurse serves as an advocate to protect the rights of all family members, including the
fetus.
• Maternal and child health nursing includes a high degree of independent nursing functions, because teaching and
counseling are so frequently required.
• Promoting health is an important nursing role, because this protects the health of the next generation.
• Pregnancy or childhood illness can be stressful and can alter family life in both subtle and extensive ways.
• Personal, cultural, and religious attitudes and beliefs influence the meaning of illness and its im- pact on the family.
Circumstances such as illness or pregnancy are meaningful only in the context of a total life.
• Maternal and child health nursing is a challenging role for a nurse and is a major factor in promoting high-level
wellness in families.
CHAPTER 1 A Framework for Maternal and Child Health Nursing 5
BOX 1.2
Common Measures to Ensure Family-Centered Maternal and Child Health Care
Principle
• The family is the basic unit of society.
• Families represent racial, ethnic, cultural, and socioeconomic diversity.
• Children grow both individually and as part of a family. Nursing Interventions
• Consider the family as a whole as well as its individual members. • Encourage families to reach out to their commu-
nity so that family members are not isolated from their community or from each other.
• Encourage family bonding through rooming-in in both maternal and child health hospital settings.
• Participate in early hospital discharge programs to reunite families as soon as possible.
• Encourage family and sibling visits in the hospital to promote family contacts.
• Assess families for strengths as well as specific needs or challenges.
• Respect diversity in families as a unique quality of that family.
• Encourage families to give care to a newborn or ill child.
• Include developmental stimulation in nursing care.
• Share or initiate information on health planning with family members so that care is family- oriented. child health
nursing is always family-centered; the family
tions develop guidelines for care in their specific areas of is considered the primary unit of care. The level of family
nursing practice. In maternal-child health, standards have functioning affects the health status of individuals,
because
been developed by the Division of Maternal-Child Health if the family’s level of functioning is low, the emotional,
Nursing Practice of the American Nurses Association in physical, and social health and potential of individuals in
collaboration with the Society of Pediatric Nurses. These that family can be adversely affected. A healthy family, on
are shown in Box 1.3. the other hand, establishes an environment conducive to
The Association of Women’s Health, Obstetric, and Neo- growth and health-promoting behaviors that sustain family
natal Nurses (AWHONN) has developed similar standards members during crises. Similarly, the health of an
individ-
for the nursing care of women and newborns. These are ual and his or her ability to function strongly influences
summarized in Box 1.4. the health of family members and overall family functioning. For these reasons, a family-
centered approach enables nurses to better understand individuals and, in turn, to provide holistic care. Box 1.2
provides a summary of key measures for the delivery of family-centered maternal and child
A FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING CARE health care.
Maternal and child health nursing can be visualized within
STANDARDS OF MATERNAL
a framework in which nurses, using nursing process, nursing theory, and evidence-based practice, care for families
AND CHILD HEALTH NURSING PRACTICE
during childbearing and childrearing years through four phases of health care:
The importance a society places on human life can best be measured by the concern it places on its most vulner- able
members—its elderly, disadvantaged, and youngest citizens. To promote consistency and ensure quality nurs- •
Health promotion
• Health maintenance
• Health restoration
• Health rehabilitation ing care and outcomes in these areas, specialty organiza-
Examples of these phases of health care as they relate to maternal and child health are shown in Table 1.1.
The Nursing Process
Nursing care, at its best, is designed and implemented in a thorough manner, using an organized series of steps, to
ensure quality and consistency of care (Carpenito, 2004). The nursing process, a proven form of problem solving
based on the scientific method, serves as the basis for assessing, making a nursing diagnosis, planning, organizing,
and evaluating care. That the nursing process is applicable to all health care settings, from the prenatal clinic to the
pediatric intensive care unit, is proof that the method is broad enough to serve as the basis for all nursing care.
Because nurses rarely work in isolation, but rather as a member of a health care team or unit, Multidisciplinary Care
Maps are included throughout the text to demonstrate the use of the nursing process for selected clients, provide
examples of critical thinking, and clarify nursing care for specific client needs. Multidisciplinary care maps rather
than nursing care plans are shown, because they not only demonstrate the nursing process but accentuate the
increasingly important role of the nurse as a coordi- nator of client care.

In addition, selected chapters also identify specific nursing outcomes using the terminology presented in the Nursing
Outcomes Classification (NOC) and nursing activities using the terminology presented in the Nursing In-
terventions Classification (NIC) developed by the Iowa Intervention Project ( Johnson et al., 2000; McCloskey &
Bulechek, 2000).
Evidence-Based Practice
Evidence-based practice involves the use of research or controlled investigation of a problem in conjunction with
UNIT 6
1 Maternal and Child Health Nursing Practice BOX 1.3
American Nurses Association/Society of Pediatric Nurses Standards of Care and Professional
Performance
Standards of Care Comprehensive pediatric nursing care focuses on helping children and their families and
communities achieve their optimum health potentials. This is best achieved within the framework of family-centered
care and the nursing process, including primary, secondary, and tertiary care coordinated across health care and
community settings. Standard I: Assessment The pediatric nurse collects patient health data. Standard II:
Diagnosis The pediatric nurse analyzes the assessment data in determining diagnoses. Standard III: Outcome
Identification The pediatric nurse identifies expected outcomes individualized to the child and the family.
Standard IV: Planning The pediatric nurse develops a plan of care that prescribes interventions to obtain
expected outcomes. Standard V: Implementation The pediatric nurse implements the interventions identified in
the plan of care. Standard VI: Evaluation The pediatric nurse evaluates the child’s and family’s progress toward
attainment of outcomes.
Standards of Professional Performance Standard I: Quality of Care The pediatric nurse systematically
evaluates the quality and effectiveness of pediatric nursing practice.
Standard II: Performance Appraisal The pediatric nurse evaluates his or her own nursing practice in relation to
professional practice standards and relevant statutes and regulations. Standard III: Education The pediatric nurse
acquires and maintains current knowledge and competency in pediatric nursing practice. Standard IV: Collegiality
The pediatric nurse interacts with and contributes to the professional development of peers, colleagues, and other
health care providers. Standard V: Ethics The pediatric nurse’s assessment, actions, and recom- mendations on
behalf of children and their families are determined in an ethical manner. Standard VI: Collaboration The
pediatric nurse collaborates with the child, family, and other health care providers in providing client care. Standard
VII: Research The pediatric nurse contributes to nursing and pediatric health care through the use of research
methods and findings. Standard VIII: Resource Utilization The pediatric nurse considers factors related to
safety, effectiveness, and cost in planning and delivering patient care.

American Nurses Association and Society of Pediatric Nurses. (2003). Scope and standards of pediatric clinical practice. Washington, D.C.:
American Nurses Publishing House.
clinical expertise as a foundation for action. Bodies of professional knowledge grow and expand to the extent that
people in that profession plan and carry out research. Nursing research, the controlled investigation of problems that
have implications for nursing practice, provides evidence for practice, upon which the foundation of nursing
grows, expands, and improves. In addition, evidence- based practice provides the justification for implementing
activities for outcome achievement, ultimately resulting in improved and cost-effective patient care.
A classic example of how the results of nursing research can influence nursing practice is the application of the re-
search carried out by Rubin (1963) on a mother’s approach to her newborn. Before the publication of this study,
nurses assumed that a woman who did not immediately hold and cuddle her infant at birth was a “cold” or unfeeling
mother. After observing a multitude of new mothers, Rubin concluded that attachment is not a spontaneous
procedure;
rather, it more commonly begins with only fingertip touch- ing. Armed with Rubin’s findings and integrating these
findings into practice, nurses became better able to differ- entiate healthy from unhealthy bonding behavior in post-
partum women and their newborns. Women following this step-by-step pattern of attachment were no longer recog-
nized as unfeeling, but normal. By documenting these normal parameters, nurses can identify women who do not
follow such a pattern, and interventions can be planned and instituted to help these mothers gain a stronger attachment
to their new infants. Additional nursing research in this area (discussed in Chapter 22) has provided further
substantia- tion about the importance of this original investigation. Evidence-based practice requires ongoing
research to substantiate current actions as well as to provide guidelines for future actions. Some examples of current
questions that warrant nursing investigation in the area of maternal and child health nursing include the following:
BOX 1.4
Association of Women’s Health, Obstetric, and Neonatal Nurses Standards and Guidelines
Standards of Professional Performance Standard I: Quality of Care The nurse systematically evaluates
the quality and effectiveness of nursing practice. Standard II: Performance Appraisal The nurse evaluates
his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations.
Standard III: Education The nurse acquires and maintains current knowledge in nursing practice. Standard IV:
Collegiality The nurse contributes to the professional development of peers, colleagues, and others. Standard
V: Ethics The nurse’s decisions and actions on behalf of patients are determined in an ethical manner.
TABLE 1.1
Definitions and Examples of Phases of Health Care
Term Definition Examples
Health promotion
Health maintenance
Health restoration
Health rehabilitation
Standard VI: Collaboration The nurse collaborates with the patient, significant others, and health care providers
in providing patient care. Standard VII: Research The nurse uses research findings in practice. Standard VIII:
Resource Utilization The nurse considers factors related to safety, effectiveness, and cost in planning and
delivering patient care. Standard IX: Practice Environment The nurse contributes to the environment of care
delivery within the practice settings. Standard X: Accountability The nurse is professionally and legally
accountable for his/her practice. The professional registered nurse may delegate to and supervise qualified person-
nel who provide patient care.
Association of Women’s Health, Obstetric, and Neonatal Nurses. (1998). Standards for the nursing care of women and newborns (5th ed.).
Washington, D.C.: Author.
• What is the most effective stimulus to encourage women
• What is the effect of market-driven health care on the to come for prenatal care or parents to bring children quality
of nursing care? for health maintenance care?
• What active measures can nurses take to reduce the in-

• How can nurses be instrumental in fostering diversity
cidence of child or intimate partner abuse? in care?
• How can nurses best help families cope with the stress
• What are the special needs of women who are discharged
of long-term health care? from a hospital or birthing center within a short time
• What are the long-term effects of violence on families, after childbirth? Of children, after ambulatory surgery? and
how can nurses help modify these effects? • How much self-care should young children be expected
• How can nurses be active in helping prevent violence (or encouraged) to provide during an illness?
in communities?
Educating clients to be aware of good health
Teaching women the importance of rubella through teaching and role modeling
immunization before pregnancy; teaching children the importance of safer sex practices Intervening to maintain
health when risk of
Encouraging women to come for prenatal care; illness is present
teaching parents the importance of safeguarding their home by childproofing it against poisoning Promptly diagnosing
and treating illness
Caring for a woman during a complication of using interventions that will return client
pregnancy or a child during an acute illness to wellness most rapidly
Preventing further complications from an ill-
Encouraging a woman with gestational ness; bringing ill client back to optimal state
trophoblastic disease to continue therapy or a of wellness or helping client to accept
child with a renal transplant to continue to take inevitable death
necessary medications
UNIT 8
1 Maternal and Child Health Nursing Practice • What do maternal-child health nurses need to know
dict but rather complement each other in the planning and about alternative therapies such as herbal remedies to
implementation of holistic nursing care. keep their practices current? The answers to these and other questions
provided by research help to bolster a foundation for specific actions and activities that have the potential to improve
maternal
Checkpoint Question 1
and child health care. The Focus on Evidence-Based Prac-
Suppose Melissa Chung asks you whether maternal tice boxes included in chapters throughout the text con- child
health nursing is a profession. What qualifies an tain summaries of current maternal and child health
activity as a profession? research studies and are designed to assist you in developing a questioning attitude
regarding current nursing practice and in thinking of ways to incorporate research findings into care.
a. Members supervise other people. b. Members use a distinct body of knowledge. c. Members enjoy good working
conditions. d. Members receive relatively high pay.
Nursing Theory
One of the requirements of a profession (together with other critical determinants, such as member-set standards,
monitoring of practice quality, and participation in research) is that the concentration of a discipline’s knowledge
flows from a base of established theory. Nursing theorists offer helpful ways to view clients so that nursing activities
can best meet client needs—for example, by seeing a pregnant woman not simply as a physical form but as a dynamic
force with important psychosocial needs, or by viewing children as extensions or active members of a family as
well as independent beings. Only with this broad theoretical focus can nurses appre- ciate the significant effect on a
family of a child’s illness or of the introduction of a new member.

Another issue most nursing theorists address is how nurses should be viewed or what the goals of nursing care
should be. At one time, the goal of nursing care could have been stated as “Providing care and comfort to injured
and ill people.” Most nurses today would perceive this view as a limited one, because they are equipped to do
preventive care as well. Extensive changes in the scope of maternal and child health nursing have occurred as health
promotion, or keeping parents and children well, has become a greater priority. A third issue addressed by nurse
theorists concerns the activities of nursing care: as goals become broader, so do activities. For example, when the
primary goal of nursing was considered to be caring for ill people, nursing actions were limited to bathing, feeding,
and providing comfort. Currently, with health promotion as a major nursing goal, teaching, counseling, supporting,
and advocacy are also common roles. In addition, with new technologies available, nurses are caring for clients who
are sicker than ever before. Because care of women during pregnancy and of children during their developing years
helps protect not only current health but also the health of the next generation, maternal-child health nurses fill these
expanded roles to a unique and special degree.

Table 1.2 summarizes the tenets of a number of common nursing theorists and suggests ways in which they could
be applied to maternal-child health care through the situation of one child. The third column of the table (“Emphasis
of Care”) demonstrates that although the theoretical bases of these approaches to nursing care differ, the result of any
one of them is to provide a higher level of care. These different theories, therefore, do not contra-
✔MATERNAL AND CHILD HEALTH NURSING TODAY

At the beginning of the 20th century, the infant mortality rate in the United States (i.e., the number of infants per
1,000 births who die during the first year of life) was greater than 100 per 1,000. In response to efforts to lower this
rate, health care shifted from a treatment focus to a preventive one, dramatically changing the scope of maternal
and child health nursing. Research on the benefits of early prenatal care led to the first major national effort to
provide prenatal care to all pregnant women through prenatal nursing services (home visits) and clinics. Today, thanks
to these and other community health measures (such as efforts to encourage breast-feeding, increased immunization,
and injury prevention), as well as many technological advances, the U.S. infant mortality rate has fallen to 6.9 per
1,000 (National Center for Health Statis- tics [NCHS], 2005). Medical technology has contributed to a number of im-
portant advances in maternal and child health: childhood diseases such as measles and poliomyelitis are almost erad-
icated through immunization; specific genes responsible for many inherited diseases have been identified; stem cell
therapy may make it possible in the next few years to replace diseased cells with new growth cells; new fertility
drugs and techniques allow more couples than ever before to conceive; and the ability to delay preterm birth and
improve life for premature infants has grown dramatically. In addition, a growing trend toward health care
consumerism, or self-care, has made many childbearing and childrearing families active participants in their own
health monitoring and care. Health care consumerism has also moved care from hospitals to community sites and
from long-term hospital stays to overnight surgical and ambulatory settings. Even in light of these changes, much
more still needs to be done. National health care goals established in 2000 for the year 2010 continue to stress the
importance of maternal and child health to overall community health (Department of Health and Human Services
[DHHS], 2000). Although health care may be more advanced, it is still not accessible to everyone. These and other
social changes and trends have expanded the roles of nurses in maternal and child health care and, at the same time,
have made the delivery
TABLE 1.2
Summary of Nursing
Theories
Terry is a 7-year-old girl who is hospitalized because her right arm was severely injured in an automobile accident. There
is a high probability she will never have full use of the arm again. Terry’s mother is concerned because Terry showed
promise in art. Previously happy and active in Girl Scouts, Terry has spent most of every day since the accident sitting in
her hospital bed silently watching television.
Theorist Major Concepts of Theory Emphasis of Care
Patricia Benner Florence Nightingale
Dorothy Johnson
Betty Neuman
Imogene King
Dorothea Orem
Madeleine Leininger
Ida Jean Orlando effectiveness of care depends on the client’s behavior
and the nurse’s reaction to that behavior. The client
Rosemarie Rizzo
Nursing is a human science. Health is a lived
Parse
experience. Man-living-health as a single unit guides
Hildegard Peplau practice. The promotion of health is viewed as the
forward movement of the personality; this is
accomplished through an interpersonal process that
orientation, identification, exploitation, and

Martha Rogers
The purpose of nursing is to move the
optimal health; the nurse should view the
whole and constantly changing and help

Sister Callista Roy
onship. Nurses grow from people to interact in the best way possible with the
The role of the nurse is to aid clients to

ractice in clinical settings.
change caused by illness; levels of
systems that must remain in
ioning. Any actual or depend on the degree of environmental
stem balance is a nursing change and state of coping ability; full adaptation
cess of action, reaction, physiologic interdependence.
Assess Terry as a whole. An expert nurse is

on; needs are identified based
perceptions, and health; the able to do this intuitively from knowledge

p the client achieve goal gained from practice. Assess the effect of
lack of arm function on Terry as a whole;
of nursing is care. To modify care to maintain function to all
re, the nurse focuses on the systems, not just musculoskeletal. Discuss
erent cultures with respect to with Terry the way she views herself and
e of the nurse is viewed as
lements of the environment illness. She views herself as a well child,
active in Girl Scouts and school; structure
erature, odors, noise, and light
care to help her meet these perceptions.
best opportunity for recovery. Assess Terry’s family for beliefs about
em that interacts with the
aimed at reducing stressors healing. Incorporate these into care.
ary, and tertiary prevention. Assess Terry as a whole. An expert nurse is
n the individual; clients are able to do this intuitively from knowledge

gained from practice. Assess the effect of
ty to complete self-care. Care lack of arm function on Terry as a whole;
mpensatory (client has no modify care to maintain function to all
ry (client participates in care); systems, not just musculoskeletal. Discuss
(client performs own care). with Terry the way she views herself and
interaction with the client;
Assess Terry’s family for beliefs about
illness. She views herself as a well child,
active in Girl Scouts and school; structure healing. Incorporate these into care.
care to help her meet these perceptions. Assess Terry as a whole. An expert nurse is
able to do this intuitively from knowledge
healing. Incorporate these into care. gained from practice. Assess the effect of
modify care to maintain function to all
able to do this intuitively from knowledge systems, not just musculoskeletal. Discuss
lack of arm function on Terry as a whole; with Terry the way she views herself and
modify care to maintain function to all
systems, not just musculoskeletal. Discuss active in Girl Scouts and school; structure
with Terry the way she views herself and care to help her meet these perceptions.
active in Girl Scouts and school; structure healing. Incorporate these into care.
Turn Terry’s bed into the sunlight; provide
healing. Incorporate these into care. adequate covers for warmth; leave her
Assess Terry as a whole. An expert nurse is comfortable with electronic games to occupy
her time. Assess for stressors such as loss
able to do this intuitively from knowledge of self- esteem and derive ways to prevent
gained from practice. Assess the effect of further loss such as praising her for
modify care to maintain function to all combing her own hair. Arrange overbed
systems, not just musculoskeletal. Discuss table so Terry can feed herself; urge her to
with Terry the way she views herself and participate in care by doing as much for
herself as she can.
illness. She views herself as a well child, Turn Terry’s bed into the sunlight; provide
active in Girl Scouts and school; structure adequate covers for warmth; leave her
care to help her meet these perceptions. comfortable with electronic games to occupy
Assess Terry’s family for beliefs about her time. Assess for stressors such as loss
of self- esteem and derive ways to prevent
healing. Incorporate these into care.
further loss such as praising her for
combing her own hair. Arrange overbed
able to do this intuitively from knowledge
table so Terry can feed herself; urge her to
lack of arm function on Terry as a whole; participate in care by doing as much for
modify care to maintain function to all herself as she can.
systems, not just musculoskeletal. Discuss Turn Terry’s bed into the sunlight; provide
adequate covers for warmth; leave her
with Terry the way she views herself and
comfortable with electronic games to occupy
illness. She views herself as a well child, her time. Assess for stressors such as loss
active in Girl Scouts and school; structure of self- esteem and derive ways to prevent
she wants most. Stress activities that allow
her to maintain contact with school, such as
doing homework or telephoning friends. Ask
participate in care by doing as much for Terry what being sick means to her. Allow
herself as she can.
Turn Terry’s bed into the sunlight; provide her to participate in care decisions based on
adequate covers for warmth; leave her her response. Plan care together with Terry.
Encourage her to speak of school and
accomplishments in Girl Scouts to retain
her time. Assess for stressors such as loss
of self- esteem and derive ways to prevent self-esteem. Help Terry to make use of her
left side as much as possible so that she
returns to school and to her previous level of
table so Terry can feed herself; urge her to functioning as soon as possible.
Ask Terry what she feels is her main need.
participate in care by doing as much for
Terry says that returning to school is what
herself as she can.
she wants most. Stress activities that allow
Turn Terry’s bed into the sunlight; provide
adequate covers for warmth; leave her her to maintain contact with school, such as
her time. Assess for stressors such as loss Terry what being sick means to her. Allow
of self- esteem and derive ways to prevent
further loss such as praising her for her to participate in care decisions based on
her response. Plan care together with Terry.
combing her own hair. Arrange overbed Encourage her to speak of school and
self-esteem. Help Terry to make use of her
participate in care by doing as much for
herself as she can. left side as much as possible so that she
returns to school and to her previous level of

functioning as soon as possible.
Ask Terry what she feels is her main need. Ask Terry what she feels is her main need.
Terry says that returning to school is what Terry says that returning to school is what
she wants most. Stress activities that allow she wants most. Stress activities that allow
her to maintain contact with school, such as her to maintain contact with school, such as
doing homework or telephoning friends. Ask doing homework or telephoning friends. Ask
Terry what being sick means to her. Allow Terry what being sick means to her. Allow
her to participate in care decisions based on her to participate in care decisions based on
her response. Plan care together with Terry. her response. Plan care together with Terry.
Encourage her to speak of school and Encourage her to speak of school and
accomplishments in Girl Scouts to retain accomplishments in Girl Scouts to retain
self-esteem. Help Terry to make use of her self-esteem. Help Terry to make use of her
left side as much as possible so that she left side as much as possible so that she
returns to school and to her previous level of returns to school and to her previous level of
functioning as soon as possible. functioning as soon as possible.
Ask Terry what she feels is her main need. Ask Terry what she feels is her main need.
Terry says that returning to school is what Terry says that returning to school is what
she wants most. Stress activities that allow National Health Goals
her to maintain contact with school, such as In 1979, the U.S. Public Health Service first initiated the for-
Terry what being sick means to her. Allow mulation of health care objectives. Health care goals were
reestablished in 2000, to be completed in 2010 (DHHS,
her to participate in care decisions based on 2000). Many of these objectives directly involve maternal and
her response. Plan care together with Terry. child health care, because improving the health of this young
Encourage her to speak of school and age group will have such long-term effects. The nation’s
priority goals (leading health indicators) are shown in Box 1.5.
left side as much as possible so that she Goals specific for each content area are highlighted in later
chapters. National health goals are intended to help everyone
returns to school and to her previous level of more easily understand the importance of health promotion
functioning as soon as possible. and disease prevention and to encourage wide participation in
Ask Terry what she feels is her main need.
improving health in the next decade. Maternal and child
Terry says that returning to school is what
she wants most. Stress activities that allow health nurses need to be familiar with these goals, because
her to maintain contact with school, such as
nurses play a vital role in helping the nation achieve these
objectives through both practice and research. The goals also
Terry what being sick means to her. Allow serve as the basis for grant funding and financing of evidence-
based practice.
her to participate in care decisions based on
her response. Plan care together with Terry.
Encourage her to speak of school and Trends in the Maternal and Child Health
Nursing Population
The maternal and child population is constantly changing
left side as much as possible so that she because of changes in social structure, variations in family
returns to school and to her previous level of lifestyle, and changing patterns of illness. Table 1.3 sum-
functioning as soon as possible. marizes some of the social changes that have occurred over
the past 20 to 30 years that have altered health care priori- ties
Assess Terry’s ability to use her left hand for maternal and child health nurses. Today, client ad-
to replace her right-hand functions, which vocacy, a philosophy of cost containment, an increased focus
are now lost; direct nursing care toward
on health education, and new nursing roles are ways in which
replacing deficit with other factors, self-
concept, role function, and skills. nurses have adapted to these changes.
Assess Terry’s ability to use her left hand
to replace her right-hand functions, which Measuring Maternal and

are now lost; direct nursing care toward Child Health
replacing deficit with other factors, self-
Measuring maternal and child health is not as simple as
concept, role function, and skills. defining a client as ill or well. Individual clients and health
UNIT 1 Maternal and Child Health Nursing Practice 10 care practitioners may have different perspectives on illness
and wellness. For example, some children with chronic but
of quality maternal and child health nursing care a contin- controllable asthma think of themselves as well; others with
uing challenge.
the same degree of involvement consider themselves ill.
Although pregnancy is generally considered a well state, some as high as 18% in 1950 to 6.4% at present (NCHS, 2005).
women think of themselves as ill during this period. A more
objective view of health is provided by national health Neonatal Death Rate
statistics.
A number of statistical terms are used to express the The first 28 days of life are known as the neonatal period, and
outcome of pregnancies and births and to describe maternal an infant during this time is known as a neonate. The neonatal
child health (Box 1.6). Statistics for these terms require death rate reflects not only the quality of care available to
accurate collection and analysis so that the nation’s health can women during pregnancy and childbirth but also the quality
be described accurately. Such statistics are useful for of care available to infants during the first month of life.
comparisons among states and for planning of future health The leading causes of infant mortality during the first 4
care needs. weeks of life are prematurity (early gestational age), low
birthweight (less than 2,500 g), and congenital anomalies.

Birth Rate Approximately 80% of infants who die within 48 hours after
The birth rate in the United States has gradually decreased birth weigh less than 2,500 g (5.5 lb). The proportion of
over the past 10 years to 13.9 per 1,000 population at infants born with low birthweight is about 7% of all births.
present (NCHS, 2005) (Fig. 1.2). Currently, the average This number rises slightly each year as better prenatal care
family in the United States has 1.2 children. Boys are born allows infants who would have died in utero
(fetal death) to be
more often than girls, at a rate of 1,050 boys to every 1,000
born and survive (Martin et al., 2005).
girls (NCHS, 2005). Births to teenaged mothers are steadily
declining, and those to women older than 40 years of age are Perinatal Death Rate
steadily increasing.
The perinatal period is defined in a number of ways. Sta-
Fertility Rate tistically, the period is defined as the time beginning when the
ending
The term fertility ratereflects what proportion of women who fetus reaches 500 g (about week 20 of pregnancy) and
about 4 to 6 weeks after birth. The perinatal death rate is the
could have babies are having them. The fertility rate is currently sum of the fetal and neonatal rates.
at 64.8%, a healthy reproductive rate for a country (NCHS,
2005). Maternal Mortality Rate
The maternal mortality rate is the number of maternal
Fetal Death Rate
deaths that occur as a direct result of the reproductive process
Fetal death is defined as the death in utero of a child (fetus) per 100,00 live births. Early in the 20th century, this rate in
weighing 500 g or more, roughly the weight of a fetus of 20 the United States reached levels as high as 600
weeks’ or more gestation. Fetal deaths may occur because of all mental illnesses, depression is the most common dis-
maternal factors (e.g., maternal disease, premature cervical order. More than 19 million adults in the United States
dilation, maternal malnutrition) or fetal factors (e.g., fetal suffer from depression. Major depression is the leading
cause of disability and is the cause of more than two
disease, chromosome abnormality, poor placental thirds of suicides each year. The objective selected to
measure progress in this area is:
attachment). Many fetal deaths occur for reasons unknown. The
fetal death rate is important in evaluating the health of a • Increase the proportion of adults with recognized
depression who receive treatment.
nation because it reflects the overall quality of maternal
health and prenatal care. The emphasis on both preconceptual Injury and Violence More than 400 Americans die each
and prenatal care has helped to reduce this rate from a number day from injuries, due primarily to motor vehicle crashes,
firearms, poisonings, suffocation, falls, fires, and drowning.
The risk of injury is so great that most persons sustain a vigorous physical activity that promotes cardiorespiratory
significant injury at some time during their lives. The fitness 3 or more days per week for 20 or more minutes
objectives selected to measure progress in this area are: per occasion.
• Reduce deaths caused by motor vehicle crashes. • Increase the proportion of adults who engage regularly,
preferably daily, in moderate physical activity for at least
• Reduce homicides.
30 minutes per day.
Environmental Quality An estimated 25% of preventable
Overweight and Obesity Overweight and obesity are
illnesses worldwide can be attributed to poor
major contributors to many preventable causes of death.
environmental quality. In the United States, air pollution
The objectives selected to measure progress in this area
alone is estimated to be associated with 50,000 premature
are:
deaths and an estimated $40 billion to $50 billion in
health-related costs annually. The objectives selected to • Reduce the proportion of children and adolescents who
measure progress in this area are: are overweight or obese.
• Reduce the proportion of persons exposed to air that • Reduce the proportion of adults who are obese.
does not meet the U.S. Environmental Protection Tobacco Use Cigarette smoking is the single most
Agency’s health-based standards for ozone. preventable cause of disease and death in the United
• Reduce the proportion of nonsmokers exposed to States. Smoking results in more deaths each year in the
environmental tobacco smoke. United States than AIDS, alcohol, cocaine, heroin,
homicide, suicide, motor vehicle crashes, and fires—
Immunization Vaccines are among the greatest public
combined. The objectives selected to measure progress
health achieve- ments of the 20th century. Immunizations
in this area are:
can prevent disability and death from infectious diseases
for individuals and can help control the spread of • Reduce cigarette smoking by adolescents.
infections within communities. The objectives selected to • Reduce cigarette smoking by adults.
measure progress in this area are:
Substance Abuse Alcohol and illicit drug use are
• Increase the proportion of young children who receive all associated with many of this country’s most serious
vaccines that have been recommended for universal problems, including violence, injury, and HIV infection.
administration for at least 5 years. The objectives selected to measure progress in this area
• Increase the proportion of noninstitutionalized adults who are:
are vaccinated annually against influenza and ever
• Increase the proportion of adolescents not using alcohol
vaccinated against pneumococcal disease.
or any illicit drugs during the past 30 days.
Access to Health Care Strong predictors of access to • Reduce the proportion of adults using any illicit drug
quality health care include having health insurance, a during the past 30 days.
higher income level, and a regular primary care provider • Reduce the proportion of adults engaging in binge
or other source of ongoing health care. Use of clinical drinking of alcoholic beverages during the past month.
preventive services, such as early prenatal care, can
serve as indicators of access to quality health care Responsible Sexual Behavior Unintended pregnancies
services. The objectives selected to measure progress in and sexually transmitted diseases (STDs), including
this area are: infection with the human immunodeficiency virus that
causes AIDS, can result from unprotected sexual
• Increase the proportion of persons with health insurance.
behavior. The objectives selected to measure progress in
• Increase the proportion of persons who have a specific this area are:
source of ongoing care.
• Increase the proportion of pregnant women who begin • Increase the proportion of adolescents who abstain
prenatal care in the first trimester of pregnancy. from sexual intercourse or use condoms if currently
sexually active.
Leading Health Indicators
• Increase the proportion of sexually active persons who
Physical Activity Regular physical activity throughout life use condoms.
is important for maintaining a healthy body, enhancing
psychologic well- being, and preventing premature death. Mental Health Approximately 20% of the U.S. population
The objectives selected to measure progress in this area is affected by mental illness during a given year; no one is
are: immune. Of
• Increase the proportion of adolescents who engage in

Department of Health and Human Services. (2000). Leading health indicators.
Washington, D.C.: DHHS.
NATIONAL HEALTH GOALS
BOX 1.5 FOCUS ON . . . NATIONAL HEALTH GOALS
11
UNIT 12
1 Maternal and Child Health Nursing Practice TABLE 1.3
Trends in Maternal and Child Health Care and Implications for Nurses
Trend Implications for Nursing
Families are smaller than in previous decades. Single parents are increasing in number.
An increasing number of women work outside the home.
Families are more mobile than previously; there is an increase in the number of homeless women and children.
Abuse is more common than ever before.
Families are more health-conscious than previously. Health care must respect cost containment.
Fewer family members are present as support in a time of crisis. Nurses must fulfill this role more than ever before. A
single parent may have fewer financial resources; this is more likely if the parent is a woman. Nurses need to inform
parents of care options and to provide a backup opinion when needed. Health care must be scheduled at times a
working parent can bring a child for care. Problems of latch-key children and the selection of child care centers need
to be discussed. Good interviewing is necessary with mobile families so a health database can be established;
education for health monitoring is important.
Screening for child or intimate partner abuse should be included in family contacts. Be aware of the legal
responsibilities for reporting abuse. Families are ripe for health education; providing this can be a major nursing role.
Comprehensive care is necessary in primary care settings because referral to specialists may no longer be an option.
per 100,000 live births. It is still that high in developing
• Greater detection of disorders such as ectopic preg- countries. In the United States at present, the maternal
nancy or placenta previa and prevention of related mortality rate has declined to a low of 6.5 per 100,000 live
complications through the use of ultrasound births (NCHS, 2005) (Fig. 1.3). This dramatic decrease can
• Increased control of complications associated with be attributed to improved preconceptual, prenatal, labor
hypertension of pregnancy and birth, and postpartum care, such as the following:
• Decreased use of anesthesia with childbirth
For most of the 20th century, uterine hemorrhage and
BOX 1.6
infection were the leading causes of death during pregnancy and childbirth. This has changed because of the in-
Statistical Terms Used to Report Maternal and Child Health
creased ability to prevent or control hemorrhage and infection, and now hypertensive disorders are the leading causes
of death in childbirth. Pregnancy-induced hyper- Birth rate: The number of births per 1,000 population. Fertility
rate: The number of pregnancies per

1,000 women of childbearing age.
tension adds to preexisting hypertensive disorders, especially in older women. Nurses who are alert to the signs
and symptoms of hypertension are invaluable guardians of the health of pregnant and postpartum women. Fetal death
rate: The number of fetal deaths
(over 500 g) per 1,000 live births. Neonatal death rate: The number of deaths per
1,000 live births occurring at birth or in the first 28 days of life. Perinatal death rate: The number of deaths of
fetuses more than 500 g and in the first 28 days of life per 1,000 live births. Maternal mortality rate: The number of
maternal deaths per 100,000 live births that occur as a direct result of the reproductive process. Infant mortality rate:
The number of deaths per
1,000 live births occurring at birth or in the first 12 months of life. Childhood mortality rate: The number of deaths
per 1,000 population in children, 1 to 14 years of age.
Infant Mortality Rate
The infant mortality rate of a country is an index of its gen- eral health, because it measures the quality of pregnancy
care, nutrition, and sanitation as well as infant health. This rate is the traditional standard used to compare the state of
national health care with that of previous years or of other countries.
Thanks to health care advances and improvements in child care, the infant mortality rate in the United States has
been steadily declining in recent years; it has reached a record low of 6.9 per 1,000 population (NCHS, 2005). Un-
fortunately, infant mortality is not equal for all people. African-American infants, for example, have a mortality rate
of almost 15% (NCHS, 2005). This difference in African- American and white infant deaths is thought to be related
to the higher proportion of births to young African-American

300
p uorgdeificepsninemow000,1repeta
200 20–24 years R1960
25–29 years
80
100 6018–19 years 30–34 years
15–19 years
40
15–17 years
35–39 years
201086 4
40–44 years 31965 1970 1975 1980 1985 1990 1995 2000 2005
NOTE: Rates are plotted on a log scale.
FIGURE 1.2 Birth rates by age of mother: United States, 1960–2004. (National Center for Health Statistics. [2004].
Births, marriages, divorces and deaths. National Vital Statistics Report, 49(1), 6.)
90
8070s htribevil000,001repshtaedlanreta 6050403020100

M 1950 1960 1970 1980
1990 2000 2005
FIGURE 1.3 Maternal mortality rates, 2004. (National Center for Health Statistics. [2004]. National Vital Statistics
Report, 50(1), 3.)
UNIT 14
1 Maternal and Child Health Nursing Practice 9.0
9.0
8.5
8.5
8.0
8.0
7.5
7.5
7.0
7.0
0.0
0.0 1993 1994 1995 1996 1997 1998 1999 2000 2005 FIGURE
1.4 Infant mortality rates per 1,000 live births for successive 12-
month periods ending with month indicated: United States, 2004. (National Center for Health Statistics. [2004]. Births,
marriages, divorce and deaths. National Vital Statistics Report, 50(1), 2.)
mothers, unequal provision of health care, and the higher
the highest gross national products in the world and is percentage of low-birthweight babies born to African-
known for its technological capabilities, would have the American women: 12%, compared with approximately
lowest infant mortality rate. However, in 2000, the U.S. in- 5% for white and Asian women (NCHS, 2005). Despite
fant mortality rate was higher than that of 27 other coun- this negative trend, the overall steady drop in total infant
tries (United Nations, 2000). mortality is encouraging (Martin et al., 2005) (Fig. 1.4).
One factor that may contribute to national differences The infant mortality rate also varies greatly from state to
in infant mortality is the type of health care available. In state within the United States (Table 1.4). For example, in
Sweden, for example, a comprehensive health care pro- the District of Columbia, the area with the highest infant
gram provides free maternal and child health care to all mortality, the rate is more than two times that in Massa-
residents. Women who attend prenatal clinics early in chusetts, the state with the lowest rate. pregnancy receive a
monetary award; this almost guaran- Table 1.5 shows the ranking of the United States com-
tees that all women will come for prenatal care. Many peo- pared with other developed countries. One would expect
ple believe that a guaranteed health care system such as this that a country such as the United States, which has one
of
would lead to lower infant mortality in the United States.
TABLE 1.4
Infant Mortality Rates per 1,000 by State
State Rate
State Rate
Massachusetts 4.8
South Dakota 6.4 New Hampshire 4.9
Wyoming 6.5 Maine 5.1
Idaho 6.6 Utah 5.3
Arizona 6.7 California 5.4
Kentucky 6.7 Minnesota 5.5
Rhode Island 6.7 Oregon 5.5
Alaska 6.8 Texas 5.5
Montana 6.9 Washington 5.5
Wisconsin 6.9 Iowa 5.8
Kansas 7.0 Colorado 6.0
Nebraska 7.0 Nevada 6.0
Florida 7.2 New Jersey 6.1
Hawaii 7.2 New York 6.1
Virginia 7.2 Vermont 6.2
Pennsylvania 7.3 Connecticut 6.4
Indiana 7.7 New Mexico 6.4
Maryland 7.7
National Center for Health Statistics. (2005). Trends in the health of Americans. Hyattsville, MD: NCHS.
State Rate
Missouri 7.7 Ohio 7.7 Illinois 7.8 North Dakota 7.8 West Virginia 7.9 Oklahoma 8.0 Michigan 8.1 Arkansas 8.3 North
Carolina 8.4 Georgia 8.7 South Carolina 9.0 Tennessee 9.0 Alabama 9.3 Delaware 9.6 Louisiana 9.8 District of
Columbia 11.4
TABLE 1.5
Infant Mortality Rate (Deaths per 1,000 Live Births) for Selected Countries, 2000
teaching mothers strict adherence to good sanitary practices, health care practitioners can help ensure that gastrointestinal
infection does not again become a major factor in infant mortality.
COUNTRY Girls Boys
1. Japan 3 4 2. Sweden 3 4 3. Finland 4 4 4. Hong Kong SAR 4 4 5. Austria 4 5 6. Belgium 4 5 7. Germany 4 5 8.

Iceland 4 5 9. Netherlands 4 5 10. Norway 4 5 11. Singapore 4 5 12. Switzerland 4 5 13. Czech Republic 5 5 14.
Denmark 5 5 15. France 5 5 16. Australia 5 6 17. Canada 5 6 18. Italy 5 6 19. Slovenia 5 6 20. Spain 5 6 21. United
Kingdom 5 6 22. Ireland 6 6 23. Israel 6 6 24. Luxembourg 6 6 25. New Zealand 6 6 26. Greece 6 7 27. Portugal 6 7 28.
United States 7 7
United Nations Statistics Division. (2000). Infant mortality. The world’s women 2000: Trends and statistics. New York: Author.
Fortunately, the proportion of pregnant women who receive prenatal care in the United States is increasing (about
80% now begin care in the first trimester). Early prenatal care is important, because it identifies potential risks and allows
preventive strategies to help reduce complications of pregnancy. The United States also differs from other countries in the
increased number of infants born to adolescent mothers (30% of infants are born to mothers younger than 20 years of age).
Because teenage pregnancy leads to increased premature births, this may result in infants being born who are not as well
prepared as others to face ex- trauterine life.
The main causes of early infant death in the United States are problems that occur at birth or shortly there- after. Prematurity,
low birthweight, congenital anomalies, sudden infant death syndrome, and respiratory distress syndrome are major causes.
Although other factors that contribute to sudden infant death syndrome are yet to be determined, the recommendation to
place infants on their back or side to sleep, made by the American Academy of Pediatrics in 1992, has led to an almost 50%
decrease in its incidence (Daley, 2004). Before antibiotics and formula sterilization practices became available,
gastrointestinal disease was a leading cause of infant death. By advocating breast-feeding and
✔Checkpoint Question 2
Nursing is changing because social change affects care. Which of the following is a trend that is occurring in nursing
because of social change? a. So many children are treated in ambulatory units that
nurses are hardly needed. b. Immunizations are no longer needed for infectious
diseases. c. The use of skilled technology has made nursing care
more complex. d. Pregnant women are so healthy today that they
rarely need prenatal care.
Childhood Mortality Rate
Like the infant mortality rate, the childhood mortality rate in the United States is also declining. In 1980, for example, the
mortality rate was about 6.4% for children aged 1 to 4 years and 3.1% for children aged 4 to 14 years; today, it is 3.0% and 1.8%,
respectively (NCHS, 2005). The risk of death in the first year of life is higher than that in any other year before age 55. Children in
the prepubescent period (age 5 to 14 years) have the lowest mortality rate of any child age group (NCHS, 2005). The most frequent
causes of childhood death are shown in Box 1.7. Motor vehicle accidents remain the leading cause of death in children, although
many of these accidents are largely preventable through education about the value of car seats and seat belt use, the dangers of
drinking/ drug abuse and driving, and the importance of pedestrian safety. A particularly disturbing mortality statistic is the high
incidence of suicide in the 15-to-24-year-old age group (more girls than boys attempt suicide, but boys are more success- ful).
Although school-age children and adolescents may not voice feelings of depression or anger during a health care visit, such
underlying feelings may actually be a primary concern. Nurses who are alert to cues of depression or anger can be helpful in
detecting these emotions and lowering the risk of suicide. The high incidence of homicide (1.5% in school-age children and 20%
in adolescents) and an increase in the number of adolescents infected with human immunodeficiency virus (HIV) are also grow-
ing concerns.
Childhood Morbidity Rate

Health problems commonly occurring in large proportions of children today include respiratory disorders (including asthma
and tuberculosis), gastrointestinal disturbances, and consequences of injuries. As more immunizations become available,
fewer children in the United States are affected by common childhood communicable diseases. For instance, the incidence of
poliomyelitis (once a major killer

UNIT 1 Maternal and Child Health Nursing Practice 16
BOX 1.7
Major Causes of Death in Childhood
Under 1 Year Congenital malformations, chromosomal

abnormalities Disorders related to short gestation age and low
birthweight Sudden infant death syndrome Newborn affected by maternal complications of

pregnancy Newborn affected by complications of placenta,
cord, or membranes Unintentional injuries Respiratory distress of newborn Bacterial sepsis of newborn
Diseases of the circulatory system Intrauterine hypoxia and birth asphyxia
1–4 Years Unintentional injuries Congenital malformations, chromosomal abnormalities Homicide Malignant neoplasms
Diseases of the heart Influenza and pneumonia Septicemia Chronic lower respiratory tract diseases
of children) is now extremely low (almost zero), because almost all children in the United States are immunized against it
(NCHS, 2005). Measles flared in incidence in the early 1990s but now is scheduled as a disease to be com- pletely eradicated
by 2010. It is important that this hap- pen, because measles encephalitis can be as destructive and lethal as poliomyelitis.
Continued education about the benefits of immunization against rubella (German measles) is also needed, because if a woman
contracts this form of measles during pregnancy, her infant may be born with severe congenital anomalies.
Although the decline in the overall incidence of preventable childhood diseases is encouraging, as many as 50% of
children younger than 4 years of age in some communities are still not fully immunized (NCHS, 2005). There is a potential
for childhood infectious diseases to increase again if immunization is not maintained as a high national priority. The advent
of HIV disease has changed care considerations in all areas of nursing, but it has particular implications for maternal and
child health nursing. Childbearing women and sexually active teenagers are at risk for becoming infected with HIV through
sexual contact or ex- posure to blood and blood products; in addition, infected women may transmit the virus to a fetus
during pregnancy through placental exchange. To help prevent the spread of HIV, adolescents and young adults must be ed-
ucated about safer sexual practices. Standard precautions must be strictly followed in maternal and child health
Disorders originating in the perinatal period Benign neoplasms
5–14 Years Unintentional injuries Malignant neoplasms Congenital malformations, chromosomal abnormalities Homicide
Suicide Diseases of the heart Chronic lower respiratory tract diseases Septicemia Cerebrovascular accident Influenza and
pneumonia
15–24 Years Unintentional injuries Homicide Suicide Malignant neoplasm Diseases of the heart Congenital malformations,
chromosomal abnormalities Chronic lower respiratory tract diseases Human immunodeficiency virus (HIV) disease Diabetes
mellitus Cerebrovascular diseases
nursing, as in other areas of nursing practice, to safeguard health care providers and other clients. Other infectious diseases that
are increasing in incidence include syphilis, genital herpes, hepatitis A and B, and tuberculosis. The rise in cases of syphilis
and genital herpes probably stems from an increase in nonmonoga- mous sexual relationships and lack of safer sex practices.
The increase in hepatitis B is due largely to drug abuse and the use of infected injection equipment. One reason for the increase
in hepatitis A is shared diaper-changing facilities in day care centers. Tuberculosis, once considered close to eradication, has
experienced a resurgence, occurring today at approximately the same rate as measles in young adults. One form occurs as an
opportunistic disease in HIV-positive persons and is particularly resistant to the usual therapy (Burgos et al., 2003).
Trends in Health Care Environment

The settings for maternal and child health care are changing to better meet the needs of increasingly well-informed and
vocal consumers.
Cost Containment
Cost containment refers to systems of health care delivery that focus on reducing the cost of health care by closely
National Center for Health Statistics. (2005). Trends in the health of Americans. Hyattsville,
MD: NCHS.
monitoring the cost of personnel, use and brands of supplies, no matter how many supplies, procedures, or personnel are
length of hospital stays, number of procedures carried out, used in care. In a managed care environment, helping to
and number of referrals requested (Schwartz, 2003). Before
curtail cost is an important nursing function. Suggestions such
the philosophy of cost containment became prominent, health
as using generic-brand supplies, never breaking into kits of
care insurance paid separately for each procedure or piece of supplies to remove a single item, and urging the use of
equipment the client received. Under managed care, the disposable supplies so that less personnel time will be spent
agency receives a certain sum of money for the client’s care, on cleaning and ster- ilizing are welcome, cost-effective
suggestions. Cost containment has had dramatic effects on The last 100 years has seen several major shifts in settings for
maternity care. At the turn of the 19th century, most births
health care, most noticeably in limiting the number of hospital
days and changing the roles of personnel. Before managed took place in the home, with only the very poor or ill giving
care, women stayed in a hospital for 3 or 4 days after child-
birth; today, they rarely stay longer than 48 hours. Before birth in “lying-in” hospitals. By 1940, about 40%
CHAPTER 1 A F
managed care, nurses completed all care procedures for
patients, no matter how small or unskilled the task. With
of live births occurred in hospitals, and today the figure has
managed care, ancillary personnel (e.g., unlicensed assistive
personnel) perform many tasks under the supervision of the risen to 98% (DHHS, 2005). Today, a less dramatic but no
nurse. This system is designed to move the registered nurse
less important trend is occurring: an increasing number of
(RN) to a higher level of function, because it makes the RN
families are once more choosing childbirth at home or in
accountable for a fuller range of services to patients. It
alternative birth settings rather than hospitals. These
accentuates point-of-service care. It also increases the
alternative settings provide families with increased control of
accountability and responsibility of RNs to delegate tasks
the birth experience and options for birth sur- roundings
appropriately. As a result of managed care, the new
advanced-practice role of case manager has been created. unavailable in hospitals. One strength of this movement is its
It is important to know the legal aspects of encouragement of family involvement in birth. It also
delegation, as identified in individual state nursing practice
increases nursing responsibility for assessment and
acts, because some laws address specific tasks and activities
professional judgment and provides expanded roles for nurse
that RNs may or may not delegate in that state. Accountability practitioners, such as the nurse-midwife. Of all births in the
for completion and quality of the task remains with the nurse,
United States, 5% currently are attended by midwives rather
so the nurse is responsible for knowing that the condition of
the patient and the skill level of the assistive person are than physicians (Martin et al., 2005). Hospitals have responded
conducive to safe delegation. There are four rules to follow to consumers’ demand for
a more natural childbirth
when delegating: environment by refitting labor and delivery suites as birthing
• Right task for the situation rooms, often called labor-delivery-recovery (LDR) or labor-
• Right person to complete the task delivery-recovery- postpartum (LDRP) rooms. Partners, family
• Right communication concerning what is to be done
• Right feedback or evaluation that the task was completed members, and other support people may remain in the room,
which is designed to be a homelike environment, and
Examples of delegation responsibility that can occur in participate in the childbirth experience (Fig. 1.5). Couplet care
maternal and child health are highlighted in the Multi- —care for both the mother and newborn by the primary nurse
disciplinary Care Maps located throughout this text.
When managed care was introduced, it was viewed as — is encouraged after the births. LDRP rooms promote a
a system that could lead to poor-quality nursing care because holistic, family-centered approach to maternal and child
it limits the number of supplies and time available for care. In health care and are appealing to many families who might
settings where it works well, however, it has increased
otherwise have opted against a hospital birth. However, LDRPs
opportunities for nurses because it rewards creativity. are not without fault. It has been argued that they are less
private for laboring families, tend to be less re- laxing for

Alternative Settings and Styles
for Health Care postpartum families, and make it difficult for nurses to manage
FIGURE 1.5 A couple, soon to be parents, share a close
the needs of women both in labor and after birth. Many moment in a birthing room.
hospitals are continuing to search for the best labor, delivery,

and postpartum options. Whether childbirth takes place at
home, in a birthing center, or in a hospital, the goal is to keep it
as natural as possible while ensuring the protection that

experienced nurse-midwives or physicians can provide.
Health care settings for children are also changing. Clients’

homes, community centers, ambulatory clinics, well-baby
clinics, schools, and group homes are some settings in
which comprehensive health care may be adminis- tered. In
these settings, a nurse may provide immunizations,
screenings, health and safety education, counseling, crisis
intervention for teens, parenting classes, and care of the ill child and family. Community-based care can provide
cost- effective health promotion, disease prevention, and patient care to a large number of children and families in
an environment that is familiar to them.

Strengthening the Ambulatory Care System
The ambulatory care system continues to broaden its base. More and more people who might otherwise have been
admitted to a hospital are now being cared for in ambulatory clinics or at home. This option has proved especially
important in the care of sick children and women who are experiencing a pregnancy complication or who want early
discharge after childbirth. Separating a child from his or her family during an illness has been shown to be
potentially harmful to the child’s development, so any effort to reduce the incidence of separation should have a
positive effect (see Chapter 35). Avoiding long hospital stays for women during pregnancy is also a prefer- able
method of care, because it helps to maintain family contact. ?

What if... Melissa Chung has to remain in the hospital after the birth of her new baby while her baby is
transported to a regional center for care? How could you help her keep in touch with her new baby?
Shortening Hospital Stays
More and more hospitals perform children’s surgeries such as tonsillectomy or umbilical or inguinal hernia repair
without requiring an overnight stay. Early on the morning of surgery, the parent and child arrive at the hospital, and
the child receives a preoperative physical examination and medication. After surgery, the child is sent to a recovery
room and then to a short-term observation unit. If the child is doing well and shows no complications by about 4
hours after surgery, he or she can be discharged. Simi- larly, women who have begun preterm labor stay in the
hospital while labor is halted and then are allowed to return home on medication with continued monitoring. The
routine hospital stay for mothers and newborns after an uncomplicated birth is now 2 days or less.
Short-term hospital stays require intensive health teaching by the nursing staff and follow-up by home care or
community health nurses. Parents must be taught to watch for danger signs in the child without being frightened. A
woman with a complication of pregnancy must be taught to watch for signs that warrant immediate attention. New
parents must be taught about their newborn’s nutritional needs, umbilical cord care, bathing, and safety
considerations, all before the euphoria and fatigue of childbirth have begun to wear off. This type of teaching is
difficult, because it includes not only imparting the facts of self-care but also providing support and reas- surance
that the client or parents are capable of this level of care.
Including the Family in Health Care
Most hospitals have developed policies that minimize the effects of separation from parents when children must be
admitted for extended stays. Open visiting hours allow parents to visit as much as possible and sleep overnight in a bed
next to their child. Parents also are allowed and encouraged to do as much for the child as they wish during a hospital
stay, such as feeding and bathing the child or administering oral medicine. Most of a parent’s time, however, is spent
simply being close by to provide a comfortable, secure influence on the child. For the same reasons, parents on a
maternity unit are encouraged to room-in and give total care to their well newborn (Box 1.8). Because parents are so
important to their child’s hospital experience and overall well-being, family-centered nursing is vital. Therefore, the
nurse’s client load will not be just four children, for example, but four children plus four sets of parents; not just a single
newborn, but his or her two parents as well.

Increase in the Number of Intensive Care Units
Over the past 20 years, care of infants and children has become extremely technical. It is generally assumed that
newborns with a term birthweight (more than 2,500 g or 5.5 lb) will thrive at birth. However, many infants are born each
year with birthweights lower than 2,500 g or who are ill at birth and do not thrive. Such infants are regularly transferred to
a neonatal intensive care unit (NICU) or in-

BOX 1.8 FOCUS ON . . .
EVIDENCE-BASED PRACTICE EVIDENCE-BASED PRACTICE
What are the ingredients of effective family-centered care?
Working on the premise that family-centered care is best achieved when a mutually beneficial partnership exists
between health care providers and families, nurse researchers attempted to identify health care practices that
promote or limit a family-centered philosophy. For the study, 34 women (mostly African-American) who were using
maternity services at a large urban hospital were interviewed as to what they liked or didn’t like about their maternity
care. The results re- vealed two important perceived barriers to family-centered maternity care: problems among
health caregivers in coordinating services and lack of patient access to services. Factors that aided effective care
were prompt response to high-risk patients and the availability of health-related support outside the hospital. The
authors concluded that each childbearing woman and her family should be treated, in clinical situations, as if they
were extraordinary. In this way, practitioners can alter routines that cause the woman and her family to lose
individualized care.
Source: Gramling, L., Hickman, K., & Bennett, S. (2004). What makes a good family-centered partnership between women and their practi-
tioners? A qualitative study. Birth, 31(1), 43–48.
tensive care nursery (ICN). Children who are undergoing cardiac surgery or recovering from near-drownings or multiinjury
accidents are cared for in a pediatric intensive care unit (PICU). Intensive care at this early point in life is one of the most costly
types of hospitalization. Ex- penses of $1,000 a day, or $20,000 to $100,000 for a total hospital stay, are not rare for care during a
high-risk pregnancy or care for a high-risk infant. As the number of these settings increases, the opportunities for advanced-
practice nurses also increase.
Regionalization of Intensive Care

To avoid duplication of care sites, it is an accepted practice for communities to establish centralized maternal or pediatric
health services. Such planning creates one site that is properly staffed and equipped for potential problems. For example, ill
newborns may be transported to a central high-risk nursery for care. High-risk pregnant women and ill children may be cared for in
a regional setting equipped with specialized resources for the diagnosis and treatment of specific health problems. When a
newborn, older child, or parent is hospitalized in a regional center, the family members who have been left behind need a great deal
of support. They may feel they have “lost” their infant, child, or parent unless health care personnel keep them abreast of the ill
family member’s progress by means of phone calls and snapshots and encourage the family to visit as soon as possible. When
regionalization concepts of newborn care first became accepted, transporting the ill or premature newborn to the regional care
facility was the method of choice (Fig. 1.6). Today, however, if it is known in advance that a child may be born with a life-
threatening condition, it may be safer to transport the mother to the regional center during pregnancy, because the uterus has
advantages as a transport incubator that far exceed those of any com- mercial incubator yet designed. An important argument
against regionalization for pediatric care is that children will feel homesick in strange settings, overwhelmed by the number of
sick children they see, and frightened because they are miles from home. An important argument against regionalization of
maternal care is that being away from her community and support net- work places a great deal of stress on the pregnant woman
and her family and limits her own doctor’s participation in her care. These are important considerations. Because nurses more than
any other health care group set the tone for hospitals, they are responsible for ensuring that clients and families feel as welcome in
the regional centers as they would have been in a small hospital. Staffing should be adequate to allow sufficient time for nurses to
comfort frightened children and prepare them for new experiences or to support the pregnant woman and her family.
Documenting the importance of such actions allows them to be incorpo- rated in critical pathways and preserves the importance of
the nurse’s role.
Increased Reliance on Comprehensive Care Settings
Comprehensive health care is designed to meet all of a child’s needs in one setting. In the past, care of children
tended to be specialized. For example, a child born with an illness (e.g., myelomeningocele, cerebral palsy) might have been
followed by a team of specialists for each facet of the problem. Such a team might include a neurologist, a physical therapist,
an occupational therapist, a psychol- ogist for intelligence quotient testing, a speech therapist, an orthopedic surgeon, and
finally, a special education teacher. The parents might need to find a special dentist who accepts clients with multiple
disabilities. Each specialist would look at only one area of the child’s needs rather than the whole child’s development.
Without extra guidance, parents would find themselves lost in a maze of visits to different health care personnel. If they were
not receiving financial support for their child’s care, they might not have been able to afford all the necessary services at
one time. It might have been difficult to decide which of the child’s problems needed to be treated immediately and which
could be left untreated without wors- ening and developing into a permanent disability. Although specialists are still
important to a child’s care, a trusted primary care provider to help parents coordinate these specialized services is essential in
today’s managed care environment. In many settings, this primary care provider, who follows the child through all phases of
care, is an advanced-practice nurse such as a family nurse practitioner, pediatric nurse practitioner, or a women’s health
nurse practitioner. Nurses can be helpful in seeing that both parents and children have all their needs met by a primary health
care provider in this way. The family must become empowered to seek out a family-centered setting that will be best for their
health (Box 1.9).
FIGURE 1.6 A nurse prepares an infant transport incubator to move a premature infant to a regional
hospital. Helping with safe movement of pregnant women and ill newborns to regional centers is an
important nursing responsibility. (© Caroline Brown, RNC, MS, DEd.)
Tips for Selecting a Health Care Setting
Q. Melissa Chung, the patient you met at the beginning

of the chapter, asks you, “With so many health care choices and settings available, how do we know which one to
choose?” A. When selecting a health care setting, use the following as a guide to help you decide what is best for your
family:
• Can it be reached easily? (Going for preventive care when well or for care when ill should not be a chore.)
• Will the staff provide continuity of care so you’ll always see the same primary care provider if possible?
• Does the physical setup of the facility provide for a sense of privacy, yet a sense that health care providers share
pertinent information so you do not have to repeat your history at each visit?
• Is the cost of care and the number of referrals to specialists explained clearly?
• Are preventive care and health education stressed (keeping well is as important as recovering from illness)?
• Do health care providers respect your opinion and ask for your input on health care decisions?
• Do health care providers show a personal interest in you?
• Is health education done at your learning level?
• Is the facility accessible to handicapped individuals?
Increased Use of Alternative Treatment Modalities

There is a growing tendency for families to consult providers of alternative forms of therapy, such as acupunc- ture or
therapeutic touch, in addition to, or instead of, traditional health care providers. Nurses have an increasing obligation to be
aware of complementary or alternative therapies, which have the potential to either enhance or detract from the
effectiveness of traditional therapy (Fletcher & Clarke, 2004; Weier & Beal, 2004). In addition, health care providers who are
unaware of the existence of some alternative forms of therapy may lose an important opportunity to capitalize on the positive
features of that particular therapy. For instance, it would be important to know that an adolescent who is about to undergo a
painful procedure is experienced at meditation, because asking the adolescent if she wants to meditate before the procedure
could help her relax. Not only could this decrease the child’s discomfort, but it could also offer her a feeling of control over a
difficult situation. People are using an increasing number of herbal remedies, so asking about these at health assessment is
important to prevent drug interactions. Ginger, for example, is frequently taken

BOX 1.9 FOCUS ON . . .
FAMILY TEACHING FAMILY TEACHING

during pregnancy to relieve morning sickness (Senyak et al., 2005).
Increased Reliance on Home Care
Early hospital discharge has resulted in the return home of many women and children before they are fully ready to care for
themselves. Ill children and women with complications of pregnancy may choose to remain at home for care rather than be
hospitalized. This has created a “second system” of care requiring many additional care providers (Asensio et al., 2005).
Nurses are instrumental in assessing women and children on hospital discharge to help plan the best type of continuing care,
devise and modify procedures for home care, and sustain clients’ morale and interest in health care during such situations as
home monitoring to prevent premature labor. Because home care is a unique and expanding area in maternal and child health
nursing, it is discussed in relation to maternal care in Chapter 16 and in relation to children in Chapter 35.
Increased Use of Technology
The use of technology is increasing in all health care settings. The field of assisted reproduction (e.g., in vitro fertilization),
with the possibility of stem cell research, is forging new pathways ( Jain et al., 2004). Charting by computer, seeking
information on the Internet, and monitoring fetal heart rates by Doppler ultrasonography are other examples. In addition to
learning these technologies, maternal and child health nurses must be able to explain their use and their advantages to
clients. Otherwise, clients may find new technologies more frightening than helpful to them.
Health Care Concerns and Attitudes
The 1980s brought about considerable change in the health care system. As we progress through the 21st century, there are
likely to be even more changes as the United States actively works toward effective health goals and improved health care for
all citizens. These steps can create new concerns.
Increasing Concern Regarding Health Care Costs

The advent of managed care has concentrated efforts on reducing the cost of health care. This has direct implications for
maternal and child health nursing, because nurses must become more cost-conscious about supplies and services. Lack of
financial ability to pay and health care provider’s in- sensitivity to cultural values are major reasons why women do not
obtain prenatal care. A woman may fear that changing jobs or not working during pregnancy may lead to loss of insurance
coverage, thereby reducing her ability to pay for services. As a result, she may continue to work long hours or in unfit
conditions during pregnancy. Nurses are challenged to help reduce costs while maintaining quality care so that prenatal care
remains available.
Increasing Emphasis on Preventive Care
A generally accepted theory is that it is better to keep individuals well than to restore health after they have become ill.
Counseling parents on ways to keep their homes safe for children is an important form of illness prevention in maternal and
child health nursing. Research supporting the facts that accidents are still a major cause of death in children and that women
still do not receive preconceptual or prenatal care are testaments to the need for much more anticipatory guidance in this
area.
Increasing Emphasis on Family-Centered Care
Health promotion with families during pregnancy or childrearing is a family-centered event, because teaching health
awareness and good health habits is accomplished chiefly by role modeling. Illness in a child is automatically a family- centered
event. Parents may need to adjust work sched- ules to allow one of them to stay with the ill child; siblings may have to
sacrifice an activity such as a birthday party or having a parent watch their school play; and family finances may have to be
readjusted to pay for hospital and medical bills. When a mother is pregnant, family roles or activities may have to change to
safeguard her health. A family may feel drawn together by the fright and concern of an acute illness. On the other hand, if an
illness becomes chronic, it may pull a family apart or destroy it. By adopting a view of pregnancy, childbirth, or illness as a
family event, nurses are well equipped to provide family-centered care. Nurses can be instrumental in including family
members in events from which they were once totally excluded, such as an unplanned cesarean birth. They can help child
health care to be family-centered by consulting with family members about a plan of care and providing clear health teaching
so that family members can monitor their own care (Fig. 1.7). Nurses play an active role in both teaching health promotion
and sustaining families through a child’s illness. In recent years, the U.S. government has recognized that the care of individual
family members is a family-

FIGURE 1.7 A nurse involves the mother in a physical exam to promote family-centered care. (© Barbara Proud.)
centered event. The Family Medical Leave Act of 1993 is a federal law that requires employers with 50 or more employees to
provide a minimum of 12 weeks of unpaid, job- protected leave to employees under four circumstances crucial to family life:
• Birth of the employee’s child • Adoption or foster placement of a child with the employee • Need for the employee to care for a
parent, spouse, or child with a serious health condition • Inability of the employee to perform his or her functions because of a
serious health condition
A serious health condition is defined as “an illness, injury, impairment, or physical or mental condition involv- ing such
circumstances as inpatient care or incapacity requiring 3 workdays’ absence” (U.S. Department of Labor, 1995). Specifically
mentioned in the law is any period of incapacity due to pregnancy or for prenatal care with or without treatment. Illness must be
documented by a health care provider. Nurse practitioners and nurse-midwives are specifically listed as those who can document a
health condition.
Increasing Concern for the Quality of Life
In the past, health care of women and children was fo- cused on maintaining physical health. More recently, however, a growing
awareness that quality of life is as important as physical health has expanded the scope of health care to include the assessment of
psychosocial facets of life in such areas as self-esteem and indepen- dence. Good interviewing skills are necessary to elicit this
information at health care visits. Nurses can help obtain such information and also plan ways to improve quality of life in the areas
the client considers most important. One way in which quality of life is being improved for children with chronic illness is the
national mandate to allow them to attend regular schools, guaranteeing en- trance despite severe illness or use of medical
equipment such as a ventilator (Public Law 99-452). Nurses serving as school nurses or consultants to schools play important roles
in making these efforts possible.
Maternal and child clients today do not fit readily into any set category. Varying family structures, cultural back- grounds,
socioeconomic levels, and individual circumstances lead to unique and diverse clients. Some women having children are
younger than ever before, and an increasing number of women are experiencing their first pregnancies after the age of 35
(Carolan, 2003). Many women are having children outside of marriage. Gay and lesbian couples are also beginning to raise
families, con- ceiving children through artificial insemination or adoption. As a result of advances in research and therapy,
women who were once unable to have children, such as those with cystic fibrosis, are now able to manage a full-term
pregnancy. Individuals with cognitive and physical challenges are also establishing families and rearing children.
Increasing Awareness of the
Individuality of Clients
UNIT 221 Maternal and Child Health Nursing Practice Many families who
client feel as important as the first by showing a warm manner
have come from foreign countries enter the U.S. health care system
and keen interest. Family Teaching displays are presented
for the first time during a pregnancy or with a sick child. This requires
throughout this text to provide insight into ways in which
a greater sensitivity on the part of health care providers to the socio-
nurses can help empower families.
cultural aspects of care. As the level of violence in the world increases,
more and more families are exposed to living in violent communities.
The incidence of abused children and pregnant women is also
increasing. All of these concerns require increased nursing attention. ? What if... In the past, children with pneu-
Empowerment of Health Care monia were always hospitalized. What if Melissa Chung
Consumers demands that her 6-year-old, diagnosed with pneumonia,
be hospitalized, even though it is your clinic’s pol- icy to
In part because of the influence of market-driven care and a have such children cared for at home by their parents?
strengthened focus on health promotion and disease pre- Would you advocate for hospitalization or not?
vention, individuals and families have recently begun to take
increased responsibility for their own health. This begins with ADVANCED-PRACTICE ROLES FOR
learning preventive measures to stay well. For some families, NURSES IN MATERNAL AND CHILD
it means following a more nutritious diet and planning regular HEALTH
exercise; for others, it can mean an entire change in lifestyle.
When a family member is ill, empowerment means learning As trends in maternal and child health care change, so do the
roles of maternal and child health nurses. All maternal
more about the illness, par- ticipating in the treatment plan, and and child health nurses function in a variety of settings as
caregivers, client advocates, researchers, case managers, and
preventing the illness from returning. Families are very
educators. Many nurses with a specified number of years of
interested in participat- ing in decision making regarding their
childbearing options. Parents want to accompany their ill direct patient care, clinical expertise, and validated com-
children into the hospital for overnight stays. They are eager pletion of pertinent continuing education programs are
for information about their child’s health and want to certified in their specialty. In addition, maternal and child
contribute to the decision-making process. They may question health nurses function in a variety of advanced-practice roles.
treat- ments or care plans that they believe are not in their Clinical Nurse Specialists
child’s best interest. If health care providers do not provide
answers to a client’s questions or are insensitive to needs, Clinical nurse specialists are nurses prepared at the
many health care consumers are willing to take their busi- master’s-degree level who are capable of acting as consul-
tants in their area of expertise, as well as serving as role
ness to another health care setting. Nurses can promote
models, researchers, and teachers of quality nursing care.
empowerment of parents and children by respecting their views Examples of areas of specialization are neonatal, maternal,
and concerns, address- ing clients by name, and regarding child, and adolescent health care; childbirth education; and
parents as important participants in their own or their child’s lactation consultation.
health, keeping them informed and helping them to make Consider, for example, how a child health clinical spe-
decisions about care. Although a nurse may have seen 25
cialist might intervene to help in the care of a 4-year-old child
clients already in a particular day, he or she can make each
with diabetes mellitus who has been admitted to the hospital.
The child is difficult to care for because he is so fearful of
families. In conjunction with a physician, an FNP can provide
hospitalization and perplexed because his parents are having
difficulty accepting his diagnosis. A clinical nurse specialistprenatal care for a woman with an uncomplicated pregnancy.
could be instrumental in helping a primary nurse organize
The FNP takes the health and pregnancy history, performs
care and in meeting with the parents to help them accept what
physical and obstetric examinations, orders appropriate
is happening. Neonatal nurse specialists manage the care of
infants at birth and in intensive care settings; they providediagnostic and laboratory tests, and plans continued care
home follow-up care to ensure the newborn remains well.
throughout the pregnancy and for the family afterward. FNPs
Childbirth educators teach families about normal birth and
how to prepare for labor and birth. Lactation consultantsthen monitor the family indefinitely to promote health and
educate women about breast-feeding and support them whileoptimal family functioning.
they learn how to do this well themselves.

Neonatal Nurse Practitioner
Case Manager A neonatal nurse practitioner (NNP) is an advanced-
A case manager is a graduate-level nurse who supervises apractice role for nurses who are skilled in the care of newborns,
group of patients from the time they enter a health care setting
until they are discharged from the setting, or, in a seamlessboth well and ill. NNPs may work in level 1, level 2, or level 3
care system, into their homes as well, monitoring the
newborn nurseries; neonatal follow-up clinics or physician
effectiveness, cost, and satisfaction of their health care. Case
groups. They also transport ill infants to different care settings.
management can be a vastly satisfying nursing role, because if
The NNP’s responsibilities include managing and carrying out
the health care setting is “seamless,” or one that follows people
both during an illness and on their return to the community,patient care in an intensive care unit, conducting normal
it involves long-term contacts and lasting relationships
(Peterson, 2004). newborn assessments and physical examinations, and
providing high-risk follow-up discharge planning (Bissell,

Women’s Health Nurse
2004).
Practitioner
A women’s health nurse practitioner is a nurse withPediatric Nurse Practitioner
advanced study in the promotion of health and prevention of
illness in women. Such a nurse plays a vital role in educating A pediatric nurse practitioner (PNP) is a nurse pre-
pared
women about their bodies and sharing with them methods to
prevent illness; in addition, they care for women with with extensive skills in physical assessment, interviewing, and
illnesses such as sexually transmitted infections, offering well-child counseling and care. In this role, a nurse interviews
information and counseling them about reproductive life parents as part of an extensive health history and performs a
planning. They play a large role in helping women remain
well so that they can enter a pregnancy in good health and physical assessment of the child (Fig. 1.8). If the nurse’s
maintain their health throughout life. diagnosis is that the child is well, he or she discusses with the
Family Nurse Practitioner
parents any childrearing concerns mentioned in the interview,
A family nurse practitioner (FNP) is an advanced- practice
gives any immunizations needed, offers necessary anticipatory
role that provides health care not only to women but to total
the nurse-midwife assumes full responsibility for the care
guidance (based on the plan of care), and arranges a return
and management of women with uncomplicated
appointment for the next well-child checkup. The nurse has pregnancies. Nurse-midwives play a large role in making
served as a primary health caregiver or as the sole health care birth an unforgettable family event as well as helping to
person the parents and child see at that visit. If the PNP ensure a healthy outcome for both mother and child (Dawley,
determines that a child has a common illness (e.g., iron 2003) (Fig. 1.9).
deficiency anemia), he or she orders the necessary
laboratory tests and prescribes appropriate drugs for LEGAL CONSIDERATIONS OF
MATERNAL-CHILD PRACTICE
Legal concerns arise in all areas of health care. Maternal and
child health nursing carries some legal concerns that extend
above and beyond other areas of nursing, because care is often

given to an “unseen client”—the fetus—or to clients who are
not of legal age for giving consent for medical procedures.
In addition, labor and birth of a neonate are considered
“normal” events, so the risks for a lawsuit are greater when
problems arise. Nurses are legally responsible for protecting
the rights of their clients, including confidentiality, and are

FIGURE 1.8 A pediatric nurse practitioner examines a accountable for the quality of their individual nursing care
one-year-old child. (© Barbara Proud.) and that of other health care team members. In a society in
which 1child abuse is of national concern, nurses are
CHAPTER
becoming increasingly responsible for identifying and
therapy. If the PNP determines that the child has a major reporting incidents of suspected
abuse in children.
illness (e.g., congenital subluxated hip, kidney disease, heart
disease), he or she consults with an associated pedi- atrician;
together, they decide what further care is necessary. Nurse
practitioners may also work in inpatient or specialty settings

providing continuity of care to hospitalized children. As
school nurse practitioners, they provide care to all children in
a given community or school setting.
Nurse-Midwife
Throughout history, the nurse-midwife,an individual ed-
ucated in the two disciplines of nursing and midwifery and
licensed according to the requirements of the American
College of Nurse-Midwives (ACNM), has played an impor-
FIGURE 1.9 A nurse-midwife plays an important role in
tant role in assisting women with pregnancy and childbearing. ensuring a safe and satisfying birth. (© Caroline Brown,
Either independently or in association with an obstetrician, RNC, MS, DEd.)
UNIT 24
1 Maternal and Child Health Nursing Practice Understanding the scope of practice (the range of services and care that
may be provided by a nurse based on state requirements) and standards of care can help nurses practice within appropriate
legal parameters. Documentation is essential in protecting a nurse and justifying his or her actions. This concern is long-
lasting, because children who feel they were wronged by health care personnel can bring a lawsuit at the time they reach
legal age. This means that a nursing note written today may need to be defended as many as 21 years into the future.
Nurses need to be conscientious about obtaining informed consent for invasive procedures and determining that
pregnant women are aware of any risk to the fetus as- Checkpoint Question 3 sociated with a procedure or test.
In divorced or blended families (those in which two adults with children from previous relationships now live together),
it is important to establish who has the right to give consent for health care. Personal liability insurance is strongly
recommended for all nurses, so that they do not incur great financial losses The best description of the FNP role is
a. To give bedside care to critically ill family members. b. To supervise the health of children up to age 18 years. c. To
provide health supervision for families. d. To supervise women during pregnancy. during a malpractice or professional
negligence suit. If a nurse knows that the care provided by another practitioner was inappropriate or insufficient, he or she
is legally responsible for reporting the incident. Failure to do so can lead to a charge of negligence or breach of duty. The
specific legal ramifications of procedures or care are discussed in later chapters that describe procedures or treatment
modalities.
ETHICAL CONSIDERATIONS OF PRACTICE
Ethical issues are increasing in frequency in health care today. Some of the most difficult decisions in health care
settings are those that involve children and their families. The following are just a few of the major potential conflicts:
• Conception issues, especially those related to in vitro fertilization, embryo transfer, ownership of frozen oocytes or
sperm, cloning, stem cell research, and sur- rogate mothers • Abortion, particularly partial-birth abortions • Fetal rights
versus rights of the mother • Use of fetal tissue for research • Resuscitation (for how long should it be continued?) • The
number of procedures or degree of pain that a child should be asked to endure to achieve a degree of better health • The
balance between modern technology and quality of life
Legal and ethical aspects of issues are often intertwined, which makes the decision-making process complex. Be- cause
maternal and child health nursing is so strongly family-centered, it is common to encounter some situations in which the
interests of one family member are in conflict with those of another. It is not unusual for the values of a client not to
match those of a health care provider. For example, if a pregnancy causes a woman to develop a serious illness, the family
must make a decision either to terminate the pregnancy and lose the child or to keep the pregnancy and work to support
the mother through the crisis. If the fetus is also at risk from the illness, the decision may be easier to make; however,
the circumstances usually are not clearcut, and the decisions that need to
✔
be made are difficult. These and other issues are bound to emerge during the course of practice. Nurses can help clients
who are facing such difficult decisions by providing factual information and supportive listening and by helping the
family clarify their values. The Pregnant Woman’s Bill of Rights and the United Na- tions Declaration of Rights of
the Child (see Appendix A) provide guidelines for determining the rights of clients in regard to health care.
Key Points
• Standards of maternal and child health nursing practice have been formulated by the American Nurses
Association, the Society of Pediatric Nurses, and AWHONN to serve as guidelines for practice.
• Nursing theory and use of evidence-based practice are methods by which maternal and child health
nursing expands and improves.
• The most meaningful and important measure of maternal and child health is the infant mortality rate. It is
the number of deaths among infants from birth to 1 year of age per 1,000 live births. This rate is declining
steadily, but in the United States it is still higher than in 27 other nations.
• Trends in maternal and child health nursing include changes in the settings of care, increased concern
about health care costs, improved preventive care, and family-centered care.
• Advanced-practice roles in maternal and child health nursing include women’s health, family, neonatal,
and pediatric nurse practitioners; nurse- midwives; clinical nurse specialists; and case managers. All of
these expanded roles contribute to make maternal and child health care an important area of nursing and
health care.
• Maternal and child health care has both legal and ethical considerations and responsibilities over and
above those in other areas of practice because of the role of the fetus and child.
Critical Thinking Exercises 1. How might family-centered care help the Chung fam-
ily, described in the beginning of the chapter? How can you explain recent changes in health care so that
Melissa might understand why her hospital stay is so much shorter this time? How can you empower the family so that they
feel more in control of what is happening to them? 2. Mrs. Chung says she has trouble paying for health
care. Other countries throughout the world have a health care delivery system based not on profit but on provision of care
for all citizens through a tax- supported program. The infant mortality rate in many of these countries is lower than in the
United States. What are some reasons that might contribute to these lower rates? 3. The age at which women are having
babies is in-
creasing. For many women such as Melissa Chung, this age is now 35 years or older. a. How do you anticipate that this
trend will change health care in the future? b. Are there special services that should be provided
for such women? c. How will this trend influence childrearing in the
future? 4. Examine the National Health Goals related to maternal, newborn, and child health. Most government-
sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore,
pertinent to these goals, that would be applicable to the Chung family and would also advance evidence-based practice?
American Nurses Association and Society of Pediatric Nurses.

(2003). Scope and standards of pediatric clinical practice. Washington, D.C.: Authors. Arsenio, O., et al. (2005). Home intravenous
antibiotics for cystic fibrosis. Cochrane Library (Oxford) (1) (CD001917). Association of Women’s Health, Obstetric, and Neonatal
Nurses. (1998). Standards for the nursing care of women and newborns (5th ed.). Washington, D.C.: Author. Bissell, G. (2004). The
phenomenon of high-level nursing practice within neonatal units: Who does it? Journal of Neo- natal Nursing, 10(1), 21–25. Burgos, M.,
et al. (2003). Effect of drug resistance on the gen-
eration of secondary cases of tuberculosis. Journal of Infectious Diseases, 188(12), 1878–1884. Carolan, M. (2003). The graying of the
obstetric population:
Implications for the older mother. JOGNN: Journal of Ob- stetric, Gynecologic, and Neonatal Nursing, 32(1), 19–27. Carpenito, L. J.
(2004). Handbook of nursing diagnosis
(10th ed.). Philadelphia: Lippincott Williams & Wilkins. Daley, K. C. (2004). Update on sudden infant death syndrome.
Current Opinion in Pediatrics, 16(2), 227–232. Dawley, K. (2003). Origins of nurse-midwifery in the United
States and its expansion in the 1940s. Journal of Midwifery and Women’s Health, 48(2), 86–95. Department of Health and Human
Services (2000). Healthy
people 2010. Washington, D.C.: DHHS. Department of Health and Human Services (2004). Births, mar-
riages, divorces, and deaths for 2000. Monthly Vital Statis- tics Report, 49(12), 1. Fletcher, P. C., & Clarke, J. (2004). The use of
complementary and alternative medicine among pediatric patients. Cancer Nursing, 27(2), 93–99.
References
Gramling, L., Hickman, K., & Bennett, S. (2004). What makes a
good family-centered partnership between women and their practitioners? Birth, 31(1):43–48. Jain, T., Missmer, S. A., & Hornstein, M.
D. (2004). Trends in
embryo-transfer practice and in outcomes of the use of assisted reproductive technology in the United States. New England Journal of
Medicine, 350(16), 1639–1645. Johnson, M., Maas, M., & Moorhead, S. (2000). Nursing out-
comes classification (2nd ed.). St. Louis: Mosby. Martin, J. A., et al. (2005). Annual summary of vital statistics.
Pediatrics, 115(3), 619–634. McCloskey, J., & Bulechek, G. (2000). Nursing interventions
classification (3rd ed.). St. Louis: Mosby. National Center for Health Statistics. (2005). Trends in the
health of Americans. Hyattsville, MD: NCHS. Peterson, V. (2004). When quality management meets case
management. Case Management, 9(2), 108–109. Rubin, R. (1963). Maternal touch. Nursing Outlook, 11,
828–829. Schwartz, P. A. (2003). Contemporary view of the effect of
managed care on the ethics in perinatal medicine. Clinics in Perinatology, 30(1), 167–180. Senyak, S., et al. (2005). Trends in alternative
medicine: What’s hot. Alternative Medicine, 1(73), 76–81. United Nations Statistics Division. (2000). The world’s women
2000: Trends and statistics. New York: Author. U.S. Department of Labor. (1995). Family Medical Leave Act.
Federal Register, 60(4), 2179. Weier, K. M., & Beal, M. W. (2004). Complementary therapies
as adjuncts in the treatment of postpartum depression. Journal of Midwifery and Women’s Health, 49(2), 96–104.
Ahluwalia, I. B., et al. (2003). Who is breast-feeding? Recent

trends from the Pregnancy Risk Assessment and Monitoring System. Journal of Pediatrics, 142(5), 486–491. Callister, L. C. (2003).
Toward evidence-based practice: U.S. trends in obstetric procedures, 1990–2000. MCN: Ameri- can Journal of Maternal/Child Nursing,
28(1), 52. Foster, J. (2004). Fatherhood and the meaning of children: An
ethnographic study among Puerto Rican partners of adolescent mothers. Journal of Midwifery and Women’s Health, 49(2), 118–125.
Kitchener, M., et al. (2005). Medicaid and community-based services: National program trends. Health Affairs, 24(1), 206–212. Nelms, B.
C. (2004). The joy of pediatrics: Working with children. Journal of Pediatric Health Care, 18(2), 55–56. Oxtoby, K. (2003). Men in
nursing. Nursing Times, 99(32),
20–23. Poole, J. H., & Long, J. (2004). Maternal mortality: A review of
current trends. Critical Care Nursing Clinics of North America, 16(2), 227–230. Porreco, R. P., et al. (2005). Expectation of
pregnancy out-
come among mature women. American Journal of Obstet- rics and Gynecology, 192(1), 38–41. Simpson, K. R., & Atterbury, J. (2003).
Trends and issues in
labor induction in the United States: Implications for clinical practice. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 32(6), 767–779. Turner, P. K. (2004). Mainstreaming alternative medicine:
Doing midwifery at the intersection. Qualitative Health Research, 14(5), 644–662.
Suggested Readings
Suggested Readings

Chapter01 A Framework For Maternal and Child Nursing

Uploaded by

Copyright:

Available Formats

Chapter01 A Framework For Maternal and Child Nursing

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chapter01 A Framework For Maternal and Child Nursing

Uploaded by

Copyright:

Available Formats

UNITONE

Maternal and Child Health

A Framework for Maternal and Child Health

practitioner puerperium scope of practice women’s health nurse practitioner

UNIT 41 Maternal and Child Health Nursing Practice

health of communities. • Maternal and child health nursing is research-

increasingly important role of the nurse as a coordi- nator of client care.

safety, effectiveness, and cost in planning and delivering patient care.

of nursing care? for health maintenance care?

• What active measures can nurses take to reduce the in-

family of a child’s illness or of the introduction of a new member.

expanded roles to a unique and special degree.

✔MATERNAL AND CHILD HEALTH NURSING TODAY

Theorist Major Concepts of Theory Emphasis of Care

Patricia Benner Florence Nightingale

and the nurse’s reaction to that behavior. The client

orientation, identification, exploitation, and

optimal health; the nurse should view the

whole and constantly changing and help

The role of the nurse is to aid clients to

cess of action, reaction, physiologic interdependence.

Assess Terry as a whole. An expert nurse is

perceptions, and health; the able to do this intuitively from knowledge

n the individual; clients are able to do this intuitively from knowledge

returns to school and to her previous level of

to replace her right-hand functions, which Measuring Maternal and

birthweight (less than 2,500 g), and congenital anomalies.

• Increase the proportion of adolescents who engage in

rate: The number of pregnancies per

to the higher proportion of births to young African-American

8070s htribevil000,001repshtaedlanreta 6050403020100

COUNTRY Girls Boys

1. Japan 3 4 2. Sweden 3 4 3. Finland 4 4 4. Hong Kong SAR 4 4 5. Austria 4 5 6. Belgium 4 5 7. Germany 4 5 8.

Childhood Mortality Rate

Childhood Morbidity Rate

poliomyelitis (once a major killer

Major Causes of Death in Childhood

Under 1 Year Congenital malformations, chromosomal

birthweight Sudden infant death syndrome Newborn affected by maternal complications of

mellitus Cerebrovascular diseases

Trends in Health Care Environment

private for laboring families, tend to be less re- laxing for

hospitals are continuing to search for the best labor, delivery,

home, in a birthing center, or in a hospital, the goal is to keep it

as natural as possible while ensuring the protection that

Health care settings for children are also changing. Clients’

an envi- ronment that is familiar to them.

method of care, because it helps to maintain family contact. ?

newborn, but his or her two parents as well.

a neonatal intensive care unit (NICU) or in-

practice nurses also increase.

Regionalization of Intensive Care

the nurse’s role.

Increased Reliance on Comprehensive Care Settings

Tips for Selecting a Health Care Setting

Q. Melissa Chung, the patient you met at the beginning

Increased Use of Alternative Treatment Modalities

important to prevent drug interactions. Ginger, for example, is frequently taken

FAMILY TEACHING FAMILY TEACHING