Exam 2 Test Plan Exam 2 has 54 questions that are multiple choice, fill in the blank, and multiple

answer. There are two math questions. The following is an approximate breakdown of questions on Exam 2: Labor & Delivery (General Nursing care of the Labor Patient, General Nursing Knowledge about Labor & Birth processes): About 20 questions Fetal Monitoring: About 8-10 questions Pain Management: About 8 questions
Postpartum Care: About 10 questions BB weekly STUDY GUIDE: WEEK 6 Upon completion of this learning unit you should be able to: Explain the five powers that according to Lowdermilk affect the labor process. Describe the anatomic structure of the bony pelvis. Recognize the normal diameters of the pelvic inlet, midplane, and outlet. Describe the anatomy and normal measurements of the fetal skull and the female pelvis. State the significance of molding of the fetal head. Describe the cardinal movements during labor and delivery. Explain fetal adaptation to labor processes. clinical Application Objectives: Recognize how the five powers affect the labor process of assigned patients. Assess maternal anatomic and physiologic adaptations to labor for assigned patients. Describe how nurses, physicians, and nurse-midwives document labor progress in the clinical setting. Plan and provide nursing care to assigned patients that supports normal labor and birth processes. What are the advantages/disadvantages of episiotomy? What are the risk factors associated with perineal trauma? systolic blood pressure increases during a first-stage contraction by approximately 10 mm assessment of maternal blood pressure between contractions provides accurate data Effacement usually precedes dilation for a Nulliparous woman but progresses simultaneously with dilation for the multiparous woman Women who want epidurals are encouraged not to ask for them during the latent phase of labor Women in the transition phase of labor do not usually respond well to massage and/or gentle touching WATCH WEEK 6 VIDEO LECTURE week 7 2. Learning Unit Objectives: Pain Managment in Labor & Delivery & Fetal Assessment Upon completion of this unit you should be able to: Compare the various childbirth preparation methods. -Describe the breathing and relaxation techniques used for each stage of labor. -Identify nonpharmacologic strategies to enhance relaxation and decrease labor pain. -Describe the types of analgesia and anesthesia used during labor and delivery, including implications for nursing care. -Compare the types of pharmacologic methods used for pain relief in each stage of labor and delivery. -Explain the use of and rationale for naloxone (Narcan) -Identify the signs of a reassuring and nonreassuring fetal heart rate (FHR) pattern. -Compare intermittent auscultation with internal and external electronic monitoring. -Describe nursing interventions that help to maintain fetal heart rate patterns within normal limits. -Describe patterns of period changes in fetal heart rate and identify the cause for each type of decleration. -Identify nursing interventions used for specific fetal heart rate patterns, including tachycardia and -bradycardia,increased and decreased variability, and -late and variable decelerations. Clinical Application Objectives: -Assess need for and safety factors related to administration of pharmacologic agents to assigned intrapartum patients. -Assist with safe administration of pain meds and evaluate maternal-fetal effects of medications on

assigned intrapartum patients. -Plan and implement nursing care that provides non-pharmacologic pain management with assigned labor patients and families. -Assist with assessment of baseline fetal heart rate and periodic changes and report any nonreassuring signs in accordance with facility guidelines. -Demonstrate Leopold s maneuvers. -Demonstrate application of the external fetal and uterine monitor. -50-80mmhg pressure is normal during a contraction. -Persistent baseline FHR above 160 beats/min is fetal tachycardia -Undetected Variability is the Absence of the expected irregular fluctuations in the baseline FHR. -Variable Deceleration is the FHR decrease at any time during a contraction in response to umbilical cord compression -Variability is the Expected irregular fluctuations of the baseline FHR of two or more cycles/min. -Fetal Bradycardia is the Persistent baseline FHR below 110 beats/min -Late Deceleration is the FHR decrease after the peak of a contraction in response to uteroplacental insufficiency -Early Deceleration is the FHR decrease shortly after onset of a contraction as a response to fetal head compression and is normal. WATCH WEEK 7 VIDEO LECTURE week 8 Learning Unit Objectives: Postpartum Physiology and Nsg. Care Upon completion of this unit you should be able to: -Describe the anatomic and physiologic changes occurring during the postpartum period. -Identify the characteristics of uterine involution and stages of lochia and describe standard measurement techniques. -List expected vital sign values, deviations from normal findings, and probable causes for deviations in the postpartum. -Identify the priorities of maternal care during the fourth stage of labor. -Identify common selection criteria for safe early postpartum discharge. -List the pros and cons of early postpartum discharge. -Develop examples of physical and psychosocial nursing diagnoses for the postpartum patient. -Identify expected outcomes for postpartum physical and psychosocial care. -Summarize nursing interventions to prevent infection and excessive bleeding. -Describe/plan nursing interventions to promote normal bladder and bowel patterns. -Describe the influence of cultural expectations on postpartum adjustment. -Identify the nurses responsibilities for discharge teaching and home care. Describe the nurses role in home visits, telephone follow-up, advice lines, support groups, and referrals to community resources. Clinical Application: -Assess, plan, implement, and evaluate nursing care for assigned postpartum patients. -Implement and evaluate teaching for assigned postpartum patients based on cultural background. -Identify postpartum patients needing community referral to provide continuity of care and promote health maintenance. -Plan and implement nursing care for assigned PP clients that will promote return of normal bowel, bladder patterns, involution, healing and prevent infection. -Plan and implement discharge teaching and preparation for home care with the parents of a newborn. -Develop and implement a teaching plan for a postpartum patient participating in an early discharge program to include signs of normal and abnormal recovery and necessary actions if problems encountered PRACTICE TESTS study notes: rubra lochia occurs in the 1st 3-5 days after birth

RhoGam should be given within _72___ hours of birth. 38 celcius = 100.4 F for nonbreastfeeding women periods return av. Of 3 mo. After childbirth. For breastfeeding women?Rubella can be given during breastfeeding. Other vaccines? maintain uterine tone and keep bladder empty to avoid heavy bleeding postpartum watch week 8 video lecture. PRACTICE TESTS NOTES: Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described; it results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR patter An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. Repositioning the woman on her side would be implemented when nonreassuring or ominous changes were noted. The physician would be called for instructions if changes were nonreassuring or ominous. Oxygen would be administered if changes were nonreassuring or ominous FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion because Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR. When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: The examiners hand should be placed over the fundus before, during, and after contractions. (The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed). Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the womans heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output.Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output. Fetal well-being during labor is assessed by: The response of the fetal heart rate (FHR) to uterine contractions (Ucs). Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Early deceleration is caused by head compression. Late deceleration is caused by

uteroplacental inefficiency. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Fetal hypoxemia would be evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding ones breath with a closed glottis and tightening the abdominal muscles. It is not the best way for the mother to push. This process stimulates the parasympathetic division of the autonomic nervous system and will produce a vagal response (decrease in heart rate and blood pressure). An alternative method would include instructing the woman to perform open-mouth and open-glottis breathing and pushing. The normal attitude of the fetus is called general flexion. Women usually experience a weight loss of 1 to 3 pounds when the onset of labor is getting close. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct just before labor begins. Passage of the mucous plug (operculum), also termed pink/bloody show, occurs as the cervix ripens. Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign that true labor has begun. Lightening is a premonitory sign indicating that the onset of labor is getting closer (but not begun). Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer (but not begun) Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1. Station of 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. The fetal attitude is the relation of fetal body parts to one another. The normal attitude is called general flexion. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. ilation of the cervix occurs by way of the drawing upward motion of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the presenting part of the fetus promotes cervical dilation. Pelvic size does not affect cervical dilation. Pressure exerted by the amniotic fluid while the membranes are intact can promote cervical dilation. carring of the cervix as a result of a previous infection or surgery may slow cervical dilation. A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: Help the woman breathe into a paper bag. -The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level. Administration of a sedative at this time could lead to neonatal respiratory depression because this woman, being in the transition phase, is nearing the birth process- there fore would be avoided whenever possible. DRUGS: Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because

tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor. Promethazine is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Butorphanol tartrate is an opioid agonist-antagonist analgesic. Nalbuphine is an opioid agonistantagonist analgesic. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects of these drugs depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA use usually results in decreased use of an analgesic. Spinal blocks are used often for c section but may be used for vaginal births, but the woman must be assisted while she is inlabor. A high incidence of after-birth headache can occur wit hspinal blocks; headaches may be prevented or mitigated to some degree by a number of methods. Epidural blocks limit the womans ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular. Lower back pain: Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Breathing techniques are usually helpful during contractions because they provide distraction; they are not necessarily targeted at back pain. Effleurage is usually helpful for relieving pain from contractions per the gate-control theory. Conscious relaxation or guided imagery techniques are usually helpful during contractions because they provide the opportunity to focus on a more pleasant situation; they are not targeted specifically toward back pain. Types of PAIN: Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain- (__________________________________) is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. BREATHING: First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Providing instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult to adhere to in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation. Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. True labor contractions are painful; false labor contractions typically are not. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor.A progression of intensity and duration indicates true labor. Because monitoring is essential to assess fetal well-being, whether to use monitoring is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and labor is progressing normally. When performing vaginal examinations on laboring women, the nurse should be guided by what principle(s)? Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to

prevent infection. Vaginal examinations should only be performed as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta. Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to alleviate cord compression would be to: The hips should be elevated using a Sims or knee-chest position when cord prolapse is detected. ***A distended bladder has a beneficial effect; it elevates the presenting part and inhibits uterine contractions, so a catheter insertion is not recommended.It is advised to keep the protruding cord moist with sterile saline until further help arrives. Never attempt to reinsert the cord because it may be injured in the process. True labor: Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor.Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor.Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor. What is an expected characteristic of amniotic fluid? Deep Yellow-stained fluid may indicate fetal hypoxia up to 36 hours before rupture of membranes, fetal hemolytic disease, or intrauterine infection.Amniotic fluid normally is a pale, straw-colored fluid that may contain white flecks of vernix.Amniotic fluid produces an alkaline result on a Nitrazine test. The presence of ferning is a positive indication of amniotic fluid. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips.Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently. The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation. PHASES of labor- 1st stage: The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish-topale pink mucus, and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The transition phase is characterized by strong- tovery strong, regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes. Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Placental separation: The placenta cannot detach itself from a flaccid (relaxed) uterus. Active management facilitates placental separation and expulsion, reducing the risk of complications.Which surface of the placenta comes out first is not clinically important.The major risk for women during the third stage of labor is postpartum hemorrhage. Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A first-degree laceration extends through the skin and superficial structures. A second-degree laceration extends through the muscles of the perineal body. A third- degree perineal laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall. Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs around day 2 or 3. Engorgement occurs at day 2 or 3 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious

consequence of bladder. Overdistention. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder (rare). However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony but the most serious concern associated with bladder distention is excessive uterine bleeding. Postpartum, the first menstrual cycle will be heavier than normal (at about 3 mo.) , and the volume of subsequent cycles (periods) will return to prepregnant levels within three or four cycles. The cervix regains its form within days; the cervical os may take longer to return to form. The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level.Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size. A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Afterpains: The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist throughout the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone.A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains. Breastfeeding intensifies afterbirth pain because it stimulates contractions. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease.Less lochia usually is seen after cesarean births.Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection. No significant changes in the maternal immune system occur during the postpartum period although the baby gets the moms IGG. IF palpating the fundus of a woman 18 hours after birth, and the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline- the nurse should Assist the woman to empty her bladder because The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4 F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homans sign and are suggestive of thrombophlebitis and should be investigated. For a woman with a boggy uterus, or bleeding, iF after massaging the fundus and having the woman void (Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage.) if the fundus does not become or remain firm with either intervention- Methergine can be administered . A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Perineal care is an important infection control measure. Washing the vulva and perineum with soap and water , Washing from symphysis pubis back toward episiotomy and Changing the perineal pad every 2 to 3 hours are appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.

The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Secondarily, consumers have demanded less medical intervention and more family-centered experiences. Hospitals are obligated to follow standards of care and federal statutes regarding discharge policies. The Newborns and Mothers Health Protection Act provided minimum federal standards for health plan coverage for mothers and their newborns. Under this act, couples were allowed to stay in the hospital for longer periods.
Hospital stays:

Discharge planning, the teaching of maternal and newborn care, begins on the womans admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.

The Kleihauer-Betke test is used to detect the amount of fetal blood in the maternal circulation. If more than 15 ml of fetal blood is present in maternal circulation, the dose of Rh immune globulin must be increased. Psychosocial components postpartum (chap 15): Expressing a strong need to review events and Exhibiting a reduced attention span is characteristic of the taking-in stage, which lasts for the first few days after birth. One week after birth, the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth. In th etaking hold stage- A woman may Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. Reestablishing her role as spouse/partner reflects the letting-go stage, which indicates that psychosocial recovery is complete. Siblings: Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children, time without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability but without overwhelming them. If a mother seems to not be bonding with the infant, pointing out the responsiveness of the baby to her mother is a tool for facilitating mother-infant attachment. eg. Show the mother how the infant initiates interaction and pays attention to her (the mother). When the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called mutuality. Mutuality extends the concept of attachment. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Bonding is the process over time of parents forming an emotional attachment to their infant. Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should Provide time for the mother to reflect on the events of and her behavior during childbirth. Once the mothers needs are met, she would be more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions during the taking in stage, using written materials to reinforce the content presented, are an effective approach. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once the baby has demonstrated adjustment to extrauterine life (either in the mother's room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents' needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires. Care providers need to knock before gaining entry. Nursing care activities should be grouped. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. During the PP blues, women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. Crying is not a maladaptive attachment response; it indicates PP blues. Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other people's reactions, providing proper discipline, and missing out visually.