Running head: OB CASE STUDY 1

OB Case Study

Chad Esola, Matthew Fleming, Travis Vargas

Kent State University

OB CASE STUDY 2

Introduction:

The patient that we will be writing about is JF. She is a 28 year old Caucasian

female. Her family circumstances were quite different than many peoples. She grew up

in a foster family throughout her childhood until the age of 18, when she then decided to

live on her own. She is a gravida-3 para-3 patient that gave birth at 34 weeks gestation

to a baby girl weighing 6 lbs. 5 oz. It was not surprising that she delivered slightly early

due to her history of preterm delivery. The doctor did have JF on weekly progesterone

injections that started on 8/22/11, to help prolong the pregnancy. Due to the difficulties

of vaginal labor/delivery she had third degree bilateral lacerations of the perineum.

When asked if she was a smoker she said yes, but she had only been smoking one to

three cigarettes a day from the time that she became pregnant. She stated that she

does not consume alcohol. She does have a history of substance abuse, particularly

cocaine; however she did not use during the pregnancy. As for other health issues, she

was treated for chlamydia in the first trimester and also had a LEEP procedure

performed at 33 weeks gestation. This procedure was performed as a precautionary

measure because JF presented with abnormal cervical cells as indicated by a pap

smear.

We felt that JF was a prime candidate for this paper. We felt this way because

she grew up in circumstances that differ from the average person and she has also

struggled with many unique situations such as her struggle with cocaine. We also felt

that she was a good candidate based upon her openness during the assessment and

OB CASE STUDY 3

care provided throughout the day. It would have been mundane to choose a patient who

had not faced any type of adversity and whom came from the so called “perfect family”.

As a result of this we decided to choose JF for this paper.

The purpose of our paper is to give the reader an opportunity to get to know JF

as a person and as a patient. We would also like to demonstrate how we as nurses

would formulate a plan of action for this patient. This plan of action will involve nursing

diagnoses, goals, interventions, rationales, and evaluations. As the paper comes to a

conclusion you as the reader should have a good understanding of JF and the care that

she will be provided with.

Content:

JF had her first prenatal visit on 8/20/11 and her estimated due date was

10/19/11. On 8/22/11 she started receiving progesterone injections and also started

Flagyl 500 mg twice a day for chlamydia. She currently lives alone with her seven year

old son but is planning on moving in with her fiancée once the baby comes home. JF

dropped out of high school and later went on to earn her GED. She stated that she is a

homemaker and has no aspirations to seek employment at this point in her life.

There were several concerns that we had based on the information that JF

provided us with. She said that she has struggled with cocaine use in the past and

smoking has been a problem too. Luckily, JF did abstain from the use of cocaine

throughout the duration of her pregnancy. However, she did indulge in the use of

cigarettes, smoking one to three per day. Based on this knowledge we would like to

OB CASE STUDY 4

focus on the risks associated with smoking during pregnancy. Some of the well-known

consequences associated with maternal prenatal smoking on the infant include: low

birth weight, growth restrictions, and premature birth (Coleman, 2007, p. 984). Low birth

weight was the most common consequence of maternal prenatal smoking, and

accounts for “20-30% of all low birth weight infants” (Davidson, Ladewig & London,

2008, p. 969). Another thing to be concerned with is the risk for infant mortality. JF did

state that she used her last cigarette on 10/3/11, which was her admission date to the

hospital. We realize that the best intervention to smoking is prevention altogether. Since

JF was already a smoker, the goal for her will be cessation of smoking. Travis did ask

her if they gave her any literature regarding tobacco use and its effects and she said

that they had.

Something that was concerning to us was the fact that, on top of being a smoker,

JF also suffered from asthma. Asthma not only has effects on the mother but it can also

affect the pregnancy as well. “Asthmatic women have an increased risk of complications

during pregnancy as a result of inadequately controlled asthma and/or some of the

asthma medications used to manage these patients” (Rocklin, 2011, p. 189). JF was on

albuterol which is a bronchodilator used to treat asthma. It is very beneficial to the fetus

if the mother properly controls her asthma throughout the pregnancy. “Controlling

asthma during pregnancy with appropriate medications leads to improved intrauterine

growth of the fetus and fewer adverse perinatal outcomes” (Rocklin, 2011, p. 189).

OB CASE STUDY 5

In terms of nutrition, JF seemed to have a fairly poor diet. She indicated that she

consumed fast food more than three times a week. We know that fast food, regardless

of which restaurant, is extremely high in fat and sodium content.

According to Dattoma (2007),

Approximately 1/3 of total kilocalories consumed by Americans are eaten

away from home. These meals contain more fat, saturated fat, cholesterol

and sodium, and less fiber, calcium and iron than meals prepared at

home. Unfortunately these are the nutrients that are most over-consumed

and under-consumed, respectively, by Americans, adding more insult to

injury. (p. 36)

Iron is especially important during pregnancy because it leads to the proper

development of red bloods cells. The pregnancy leads to an increased need for red

blood cells because the mother supplies blood flow to the fetus. JF was on a prenatal

vitamin (plus iron) to ensure the proper development of red bloods cells. As nurses it

would be our responsibility to inform her of the necessity of making wise nutritional

choices.

JF’s onset of labor started at 16:02 on October 3rd, 2011. She entered the first

stage of labor at 16:30. The first stage of labor is divided into three phases: the latent

phase, active phase, and transition phase. These phases are all marked by differing

amounts of cervical dilation as well as length of contractions. During the latent phase

the cervix dilates 0-3 cm, contractions last around 45 seconds and occur irregularly. JF

OB CASE STUDY 6

was in the latent phase from 16:30 until 22:01. The next phase that occurred was the

active phase. This phase entails dilation of the cervix from 4-7 cm, contractions that last

about 60 seconds and start to occur more regularly, about every 2-3 minutes. She was

in the active phase from 22:01 until 00:15. Following the active phase she then entered

into the transition phase. During the transition phase the cervix dilates 8-10 cm until

effacement is complete, contractions last 60-90 seconds and occur every 1 ½ to 2

minutes. JF was in the transition phase from 00:15 to 00:56.

For our patient the second stage of labor progressed very rapidly lasting only 25

minutes. During this stage the crown of the baby’s head is visible and the mother

actively participates in pushing. JF had a vaginal delivery but the doctor did not perform

an episiotomy. As a result she suffered from third degree bilateral lacerations of the

perineum. The baby girl was born at 01:20 on October 4th, 2011. She weighed 6 lbs. 5

oz. with a head circumference of 33 cm. The infant’s vital signs after birth were as

follows: apical pulse was 155 beats per minute, respirations were 61 breaths per

minute, and the temperature was 36.7° Celsius. All of the baby’s reflexes were within

normal limits. The gestational age determined by the Ballard score was 34 weeks. The

baby received an Apgar score within the first minute of birth which was 7, and a

subsequent Apgar score at five minutes which was 8. The patient then entered the third

stage of labor which is when the placenta is delivered. It took JF just over a minute to

deliver the placenta.

OB CASE STUDY 7

On JF’s second day postpartum (the day we were there, 10/5/11) her vitals were

within normal limits. Her apical pulse was 85 beats per minute, respirations were 16

breaths per minute, temperature was 37.1° Celsius, and her blood pressure was

118/76. Throughout the day JF’s pain remained fairly consistent at about 5 on a scale of

0-10. We did notice that she had a moderate amount of lochia rubra on her peri pad.

This was an expected finding due to the fact that it was the second day postpartum and

she had bilateral lacerations of the perineum. We did not expect any postpartum

hemorrhage because JF’s fundus was firm/midline at a level of -2 finger breaths below

the umbilicus. JF seemed to be bonding very well with her baby, as evident by her

nurturing nature during feedings and other care of the baby such as diaper changes.

Lab Results and Analysis:

Prenatal Data

Prenatal Tests Norms Patient Results Analysis

Type & Rh Rh+ A+, Rh+ Patient does not need Rhogam (a medicine that prevents hemolysis of red blood cells).

Hematocrit and

Hemoglobin

34-46%

12-16 g/dl

Information wasn’t obtained for both.

We could not locate any information regarding prenatal H&H.

VDRL/RPR

(syphilis)

Non-reactive Non-reactive Our patient did not have syphilis.

Rubella Immune Immune This patient does not run a risk of developing rubella.

Urine Culture & Normal Negative There was no trace of bacteria or other

OB CASE STUDY 8

Sensitivity contaminants in the urine.

Sickle Cell Negative Not available This test was not done on our patient because she is Caucasian. Therefore she does not run the risk for sickle cell.

Chlamydia/Gonorrhea Negative Positive for Chlamydia

Our patient tested positive for chlamydia and was medicated with Flagyl.

Quad Screen (Triple

Test)

Negative Negative The infant tested negative for TND, Down’s syndrome, and Trisomy 18.

One hour Glucose

Tolerance test

<180 mg/dl 125 mg/dl Our patient was not diabetic nor did she display any signs of gestational diabetes.

Glucose Fasting: 1

hour, 2 hours, and 3

hours

There was no need to obtain this information because the one hour glucose tolerance test was found to be within normal limits.

Postpartum Data

Tests Norms Patient Results Analysis

WBC 4.5-10.8x103/mcL 11x103/mcL Our patient had bilateral perineal lacerations which puts her at risk for infection.

Platelets 150-450x103/mcL 200x103/mcL This is within normal limits.

OB CASE STUDY 9

Lymphocytes 20-40% 25% This is within normal limits.

Monocytes 2-13% 7% This is within normal limits.

Neutrophil 50-75% 78% This number indicates that our patient may have an infection present.

Eosinophil 0-6% 4% This is within normal limits.

Basophil 0-2.5% 1% This is within normal limits.

HGB 12-16 g/dl 10.7 g/dl This may indicate a decreased ability for blood to carry oxygen.

HCT 34-46% 32% Most likely due to blood loss during pregnancy and perineal damage.

Newborn Labs

Tests Norms Patient Results Analysis

Blood type/Rh positive A+/positive Patient does not need Rhogam (a medicine that prevents hemolysis of red blood cells).

Medications:

Newborn Medications

Medication Dose, Route Indications for Use

Possible Side Effects

Nursing Interventions

OB CASE STUDY 10

Hepatitis B

Vaccine

0.5 ml, IM (typically injected into the vastus lateralis)

Prevents the infant from contracting Hepatitis B.

Possible pain, swelling, and tenderness at the injection site.

You will want to monitor the site for any bleeding, and also make sure the infant shows no signs of allergic reaction.

Erythromycin Topical ointment applied to the eyes.

This prevents any complications of the eyes such as blindness.

Nausea, vomiting, rashes, and abdominal pain.

Assess for infection at beginning and during therapy.

Vitamin K 0.5-1 mg, IM (within one hour of birth, infant was administered 0.5 mg)

Prevention of bleeding due to hypoprothrombin-emia.

Gastric upset, hyperbilirubin-emia, pain, and swelling at the injection site.

Monitor for frank and occult bleeding, pulse and blood pressure frequently.

Maternal Intrapartum/Postpartum Medications

Medication Dose, Route Indications for Use

Possible Side Effects

Nursing Interventions

metronidazole

(Flagyl)

500 mg, PO BID

Disrupts DNA and protein synthesis in susceptible organisms. Our patient was receiving this to treat chlamydia.

Abdominal pain, anorexia, seizures, and dizziness.

Assess for infection at beginning and throughout therapy.

albuterol 2-4mg, 3-4 times daily, not exceeding 32 mg per day, PO

Relaxes the smooth airway causing bronchodilation.

Chest pain, palpitations, nervousness, and restlessness.

Assess lung sounds, pulse, and blood pressure before and after administration.

progesterone 100-150 mg (single dose) or 5-10 mg

Restoration of hormonal balance with

Pulmonary embolism, thromboembolism,

Blood pressure should be monitored

OB CASE STUDY 11

daily for 6-8 days, IM

control of uterine bleeding. These shots were given to our patient to prolong her pregnancy.

and possible irritation at the injection site.

periodically throughout therapy. Monitor intake and output ratios, and weekly weights.

ibuprofen

(Motrin)

200-400 mg q 4-6 hours (do not exceed 1200 mg per day), PO

Decreases pain and inflammation.

GI bleeding, exfoliative dermatitis, headache, dizziness, and drowsiness.

Assess for pain prior to, and 1-2 hours following administration.

hydrocodone

(Vicodin)

325-650 mg q 4-6 hours (do not exceed 4 g per day), PO

Decrease in severity of moderate pain.

Hepatic failure, renal failure, leukopenia, neutropenia, and rash.

Assess type, location, and intensity of pain prior to, and 30-60 minutes following administration.

Dermoplast 60 ml, topical It is applied to the perineal area to decrease inflammation and pain.

Edema, dryness, secondary infection, and burning.

Check skin daily to assess the amount of inflammation. Notify physician if there is any positive findings.

Nursing Diagnosis #1: Pain associated with perineum lacerations (Davidson, London

& Ladewig, 2012). Rationale: The patient has experienced a lot of pain due to the tears

in her perineum after giving birth.

Short Term Goal: Pain will report decreased pain during clinical shift.

Interventions:

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1. Assess the patient’s level of pain every two hours. Rationale: Assessing the

patient’s pain level more frequently will help keep the pain at a lower level.

Keeping the pain at a lower level requires less pharmacologic intervention.

a. Encourage the patient to report pain that is of a lower intensity (1-4)

(Davidson, London & Ladewig, 2012). Rationale: Encouraging the patient

to report more mild pain will prevent the level from escalating to a level

that is unbearable and will require a lot more intervention

(pharmacological) (Davidson, London & Ladewig, 2012).

b. Assess the effectiveness of any pain medication to see if it was

successful. Rationale: If the pain is not relieved then the medication did

not take its proper effect and the client should be ordered something new.

2. Teach the client non pharmacological methods to control pain. Rationale:

Teaching the client other methods for pain control can decrease the reliance on

drugs.

a. Teach the client to use breathing exercises to help reduce pain.

Rationale: Using controlled breathing exercises can help to keep down

stress levels and relieve pain (Davidson, London & Ladewig, 2012).

b. Suggest diversion activities like movies, music or visit with family

members. Rationale: Having this patient engage in activities will help to

take her mind off of any pain she may be experiencing (Davidson, London

& Ladewig, 2012).

OB CASE STUDY 13

Long Term Goal: The patient will be free of pain upon leaving the hospital.

Interventions:

1. Encourage the client to express any worries or concerns while hospitalized.

Rationale: Allowing the client to talk about concerns will help to reduce her

stress level and ultimately decrease her pain.

a. Ask open ended questions to the client during conversation. Rationale:

Asking open ended questions will allow for the client to express any

concerns.

b. Reassure the client that it is normal to feel pain in the immediate post

partum days. Remind the client that the pain is only temporary (Davidson,

London & Ladewig, 2012).

2. Encourage the client to rest while hospitalized. Rationale: Since the client is still

in the care of the hospital it is a great opportunity for her to get as much rest as

possible.

a. Offer to take the baby to the nursery. Rationale: Taking the baby to the

nursery will allow the client to achieve adequate rest.

b. Offer the client materials to promote good hygiene and

Evaluation: The short term goal was met. The client was able to maintain a pain level

of 2 throughout the clinical day. The long term goal was an ongoing assessment and the

patient was still admitted to the hospital at the end of the clinical day.

OB CASE STUDY 14

Nursing Diagnosis #2: Risk for Infection related to vaginal laceration. Rationale: The

tear in the perineum poses a potential risk for infection due to its location (Davidson,

London & Ladewig, 2012).

Short Term Goal: The client will show no signs of infection during the clinical shift.

Interventions:

1. Encourage the client to follow proper perineal hygiene. Rationale: This will

ensure that the patient is not being exposed to bacteria and that the wound site is

healing properly.

a. Encourage the client to wipe from front to back. Rationale: Wiping from

front to back will prevent the client from introducing bacteria from fecal

matter to the wound site.

b. Teach the client to use the sitz bath. Rationale: Using the sitz bath will

promote healing to the injured area by keeping it clean as well as allowing

blood to flow more easily to the area (Davidson, London & Ladewig,

2012).

2. Teach the client about the benefits of consuming a balanced diet to promote

healing. Rationale: It is important to educate the patient that eating a high calorie

and protein diet will enhance the healing process (Davidson, London & Ladewig,

2012).

a. Provide the client with the meal menu and explain which choices are the

most appropriate. Rationale: Providing the client with the information and

OB CASE STUDY 15

giving her the choice lets the patient remain in control while choosing

appropriately.

b. Educate the patient on the role protein has in the healing process.

Rationale: This helps the client understand the importance of sticking to

this meal plan until her tears have healed.

Long Term Goal: The client will remain free from infection until the injured area has

healed.

Interventions:

1. Teach the patient about proper hand washing. Rationale: Promoting hand

washing will decrease the risk of introducing bacteria and other harmful

organisms to the perineum.

a. Educate the patient about the effects hand washing has on preventing

infections. Rationale: Informing the patient of the many benefits of hand

washing will help her to understand its importance and hopefully be

effective (Davidson, London & Ladewig, 2012).

b. Teach the client how to properly wash her hands for one minute.

Rationale: Teaching/observing the client was her hands ensures that she

understands proper technique and that hand washing will be effective.

2. Encourage the patient to look for signs and symptoms of infection after

discharge. Rationale: This will help to catch a possible infection early and

prevent it from spreading (Davidson, London & Ladewig, 2012).

OB CASE STUDY 16

a. Teach the client about the signs of infection. Rationale: Teaching the

client to look for signs like: redness, swelling and a foul smell will help to

catch the infection early. It will also give the client a sense of confidence

and control over the situation (Davidson, London & Ladewig, 2012).

b. Encourage the client to contact the doctor if an infection is suspected.

Rationale: This will help the client obtain the proper resources to promote

healing.

Evaluation: The short term goal was met. The client did not present with any signs of a

possible infection during the clinical shift. She was very receptive to the teaching about

maintaining proper perineal care and verbalized understanding. The long term goal was

still an ongoing assessment. The client seemed very confident in the regards to

preventing infection in the affected area at the end of the shift.

Nursing Diagnosis #3: Imbalanced nutrition related to in ability to properly latch.

Rationale: The baby has had many failed attempts to properly feed and is not receiving

the proper amount of calories (Davidson, London & Ladewig, 2012).

Short Term Goal: The baby will increase calorie intake during the clinical shift.

Interventions:

1. Assess the mother’s method of breastfeeding. Rationale: Assessing the

mother’s method will help to evaluate the effectiveness of the feeding.

OB CASE STUDY 17

a. Watch the mother while she attempts to breastfeed. Rationale: This will

allow the nurse to provide suggestions to promote a more positive

outcome.

b. Assess the mother’s placement of the baby while feeding. Rationale:

Ensure that the baby’s mouth is properly placed on the breast so that he

can achieve a successful latch.

2. Teach the patient breastfeeding techniques. Rationale: Providing breastfeeding

knowledge will help the mother gain confidence in her ability to properly breast

feed.

a. Provide educational materials for the patient. Rationale: This will provide

the client with information on a variety of ways. This will allow the client to

experiment with what works best for her. It also allows her to feel in control

by allowing her to choose her method.

b. Set up a consultation with the lactation consultant. Rationale: Calling in

the lactation consultant to work with the mom will give her a different

perspective on the issue and allows time for the mother to work one on

one for an extended amount of time.

Long Term Goal: The baby will learn to properly latch onto the breast and receive

adequate intake 8 to 12 times per day. Rationale: This will allow the baby to achieve his

recommended weight for his age and ensure he is getting a balanced diet (Davidson,

London & Ladewig, 2012).

OB CASE STUDY 18

Interventions:

1. Encourage the mother to make frequent attempts to breastfeed throughout the

day. Rationale: This will hopefully help the baby get into a routine of eating

frequently. It will also help him to achieve a healthy weight as well as help for

bonding to occur.

a. Encourage the mother to allow plenty of down time around feeding times.

Rationale: This will help to create a positive experience for both mom and

baby.

b. Educate the mother on the use of Lanolin cream that can be applied to

cracked or sore breasts. Rationale: Frequent attempts to feed may cause

the mother’s nipples to become dry and cracked. Application of the

Lanolin cream will help to ease this discomfort and promote frequent

feedings.

2. Encourage the mother to supplement breastfeeding with pumped breast milk and

formula. Rationale: Even though the mother prefers to breastfeed providing

pumped breast milk allows for the baby to get the same milk just in a different

way. The formula will help to supplement when breastfeeding or pumping is not

possible. Regardless, the baby meeting the overall goal of receiving the proper

amount of calories.

a. Provide educational information that supports the use of a breast pump

and formula in addition to breastfeeding. Rationale: The mother may have

doubts about the baby receiving his feedings in any other methods

OB CASE STUDY 19

besides by breast. This helps to provide the mother with reassurance that

these methods are acceptable as well.

b. Encourage the mother to weigh the baby weekly to assess for weight gain.

Rationale: Weighing the baby weekly will help to provide information

about the baby’s nutritional status.

Evaluation: The short term goal of increasing the baby’s overall caloric intake was met.

The mother, with the help of the nurses and lactation consultant was able to get the

baby to latch and breastfeed until satisfied. The long term goal was an ongoing

assessment. However, the mother did seem very confident in her ability to breastfeed at

the end of the shift.

Nursing Diagnosis #4: Stress Overload related to lack of support with newborn child.

Rationale: With the patient’s husband deployed elsewhere in the military the patient is

left with minimal support (Davidson, London & Ladewig, 2012).

Short Term Goal: The patient will remain free from stress during the hospital stay.

Interventions:

1. Encourage the patient to express any worries or concerns pertaining to the care

of the child. Rationale: This will allow the nurse to get an idea of the issues

related to the care of the baby that may be upsetting.

a. Ask open ended questions related to the mother’s support system.

Rationale: Open ended questions will allow the mother to express any

worries and help her to reflect.

OB CASE STUDY 20

b. Allow the patient to ask questions pertaining to the care of the baby.

Rationale: Allow the mother to ask questions will help her to gain more

knowledge and give confidence in herself as she goes home with limited

support.

2. Provide the patient with techniques to help reduce stress. Rationale: Techniques

to reduce stress will help to calm the mother and give her time to reflect on the

positive things in her life.

a. Provide the client with activities that the client finds enjoyable. Rationale:

Enjoyable activities will help to put the client at ease and temporarily

relieve current stress (Davidson, London & Ladewig, 2012).

b. Encourage the patient to list short term goals related to the care of her

child. Rationale: Listing personal short term goals will help the patient to

feel in control and reflect on her current situation.

Long Term Goal: The patient will remain stress free upon discharge from the hospital.

Interventions:

1. Provide the client with information to community resources that will help with the

care of her child. Rationale: Community resources will help to provide care to

the patient’s child while she is at work and will prevent her from becoming

overwhelmed.

a. Refer the client to free child care services. Rationale: This will allow the

patient to resume some normal parts of her life and provide for her child.

OB CASE STUDY 21

b. Encourage the patient to contact her social worker if additional help is

desired. Rationale: The social worker will be able to obtain additional

information about various opportunities for assistance through state

projects and community driven services.

c. Suggest a support group for the patient. Rationale: Joining a support

group for women who are in the same situation at the patient will help her

relate to others who are experiencing similar things.

2. Encourage the patient to participate in stress relieving activities in her spare time.

Rationale: Picking up hobbies will help channel the clients stress in a positive

manor.

a. Suggest exploring a new hobby. Rationale: Exploring a new hobby will

help to channel the client’s stress into a productive activity.

b. Teach the client to set weekly goals. Rationale: Setting weekly goals will

help the client lay out a plan to deal with life’s stressors and help prioritize

activities.

Evaluation: The short term goal was achieved. The patient did not seem stressed out

at the end of the clinical shift. She expressed her concerns for balancing her life with

care of her new baby. The long term goal was an ongoing assessment but the mother

was receptive to methods to reducing stress and seemed relieved after discussing

various issues with her husband.

Conclusion:

OB CASE STUDY 22

One aspect of our patient that we were unable to further research was JF’s

upbringing in a foster family. Based on JF’s reaction while talking about her childhood,

we could tell that this was sensitive subject. She would often look down and try to avoid

questions that were asked about her background. She did tell us that there were times

throughout her life when she felt like there was no one there for her to lean on.

This year, throughout our clinical rotations, we noticed how easily communication

can breakdown between the nurse and the student caring for the same patient. “While

dual assignments are necessary, communication breakdowns regarding who will

administer medications to patients, what medications have been administered, and

which medications should be held, have resulted in dose omissions and the

administration of extra doses” (Nurse Advise, 2008, p. 1). We have come to realize the

best way to provide the patient with the best possible care is to have open and clear

communication between students, nurses, and patients. As for our specific patient and

her newborn daughter, we would like their care to be directed towards promoting health

and wellness. We would want to educate the mother about the programs available to

help her with her smoking addiction, as well as her problems with substance abuse.

OB CASE STUDY 23

Works Cited

Coleman, T. (2007). Recommendations for the use of pharmacological smoking

cessation strategies in pregnant women. CNS Drugs, 21(12), 983-993.

Dattoma, L. N. (2007). A review of dietary standards, guidelines and nutrition education

resources for the oral health professional. Nutrition, 36-38.

Davidson, M. R., London, M. L., & Ladewig, P. W. (2012). Olds Maternal-Newborn

Nursing & Women's Health, Across the Lifespan. Upper Saddle River, New

Jersey: Prentice Hall.

Rocklin, R. E. (2011). Asthma, asthma medications and their effects on maternal/fetal

outcomes during pregnancy.Reproductive Toxicology, (32), 189-197.

(2008). Error-prone conditions that lead to student nurse-related errors. Nurse Advise-

ERR, 6(4), 1-3.