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11th Edition

Deitra Leonard Lowdermilk, RNC-E, PhD, FAAN
Clinical Professor Emerita, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Shannon E. Perry, RN, PhD, FAAN
Professor Emerita, School of Nursing, San Francisco State University, San Francisco, California
Kitty Cashion, RN-BC, MSN
Clinical Nurse Specialist, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
Kathryn Rhodes Alden, RN, MSN, EdD, IBCLC
Clinical Associate Professor, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Associate Editor
Ellen F. Olshansky, PhD, RN, WHNP-BC, NC-BC, FAAN
Professor, Program in Nursing Science, University of California, Irvine, Irvine, California
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Book Details
 1634 p
 File Size 
 44,997 KB
 File Type
 PDF format
 2016 by Elsevier Inc 
 2012, 2007, 2004, 2000, Mosby, Inc.,
  an affiliate of Elsevier Inc

About the Authors
Deitra Leonard Lowdermilk is Clinical Professor Emerita, School of Nursing, University of North
Carolina at Chapel Hill. She received her BSN from East Carolina University and her MEd and PhD in
Education from UNC-CH. She is certified in In-Patient Obstetrics by the National Certification Corporation.
She is a fellow in the American Academy of Nursing. In addition to being a nurse educator for more than 34 years, Dr. Lowdermilk has clinical experience as a public health nurse and as a staff nurse in labor and delivery, postpartum, and newborn units, and has worked in gynecologic surgery and cancer care units. Dr. Lowdermilk has been recognized for her expertise in nursing education. She has repeatedly been selected as Classroom and Clinical Teacher of the Year by graduating seniors. She was a recipient of the Educator of the Year Award from both the District IV Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the North Carolina Nurses Association. She also received the 2005 AWHONN Excellence in Education Award.
She is active in AWHONN, having served as chair of the North Carolina Section of AWHONN and has
served as chair and member of various committees in AWHONN at the national, district, state, and local
levels. She has served as guest editor for the Journal of Obstetric, Gynecologic and Neonatal Nursing and served on editorial boards for other publications. Dr. Lowdermilk also is coauthor of Maternity Nursing (8th edition) and Maternal Child Nursing Care (5th edition).
Dr. Lowdermilk’s most significant contribution to nursing has been to promote excellence in nursing
practice and education in women’s health through integration of knowledge into practice. In 2005 she
received the first Distinguished Alumni Award from East Carolina University School of Nursing for her
exemplary contributions to the nursing profession in the area of maternal-child care and the community.
She was also Alumna of the Year for East Carolina University in 2005, and was selected as one of the 100 Incredible ECU Women in 2007 for Outstanding Leadership Among Women in the first 100 years of the university’s founding.
In fall 2010, the East Carolina University College of Nursing named the Neonatal Intensive Care and
Midwifery Laboratory in honor of Dr. Lowdermilk. In 2011 she was named one of the first 40 nurses
inducted into the College of Nursing Hall of Fame.

Shannon E. Perry is Professor Emerita, School of Nursing, San Francisco State University, San Francisco, California. She received her diploma in nursing from St. Joseph Hospital School of Nursing, Bloomington, Illinois; a baccalaureate in Nursing from Marquette University, an MSN from the University of Colorado Medical Center, and a PhD in Educational Psychology with a Specialization in Child Development from Arizona State University. She completed a 2-year postdoctoral fellowship in perinatal nursing at the University of California, San Francisco, as a Robert Wood Johnson Clinical Nurse Scholar.
Dr. Perry has had clinical experience as a staff nurse, head nurse, and supervisor in surgical nursing,
obstetrics, pediatrics, gynecology, and neonatal nursing. She has served as an expert witness and legal
consultant. She has taught in schools of nursing in several states for more than 30 years and was interim
director and director of the School of Nursing and director of a Child and Adolescent Development
baccalaureate program at SFSU. She was Marquette University College of Nursing Alumna of the Year in 1999, and was the University of Colorado School of Nursing Distinguished Alumna of the Year in 2000. She received the San Francisco State University Alumni Association Emeritus Faculty Award in 2005 and the Excellence in Education Award from the Beta Upsilon chapter of Sigma Theta Tau International (STTI) in 2012.
She is coauthor of Maternity Nursing (8th edition), Maternal Child Nursing Care (5th edition), and Clinical Companion for Maternity & Newborn Nursing (2nd edition) and has authored numerous chapters and articles on maternal-newborn topics and the legal aspects of nursing. She is a fellow in the American Academy of Nursing, a member of AWHONN, Arizona Nurses Association (AzNA), and National League for Nursing (NLN), first vice president of the American Association for the History of Nursing (AAHN), and a member of the AAHN Communications Committee and the STTI Foundation Fellows Committee. Dr. Perry’s experience in international nursing includes teaching international nursing courses in the United Kingdom, Ireland, Italy, Thailand, Ghana, and China and participating in health missions in Ghana, Kenya, and Honduras. She is participating in establishing a school of nursing in Kenya, has supported the establishment of the library, and has had a wing of a dormitory named after her. For her “exemplary contributions to nursing, public service, and selfless commitment and passion in shaping the future of international health,”
she received the President’s Award from the Global Caring Nurses Foundation, Inc., in 2008. In January
2012, she and 47 other women climbed Mt. Kilimanjaro, the highest mountain in Africa, to raise awareness of human trafficking and to raise funds to support projects to combat human trafficking.
Kitty Cashion Kitty Cashion is a Clinical Nurse Specialist in the Maternal-Fetal Medicine Division, College of Medicine, Department of Obstetrics and Gynecology at the University of Tennessee Health Science Center in Memphis. She received her BSN from the University of Tennessee College of Nursing in Memphis and her MSN in Parent-Child Nursing from Vanderbilt University School of Nursing in Nashville, Tennessee. Ms. Cashion is certified as a high risk perinatal nurse through the American Nurses Credentialing Center (ANCC).
Ms. Cashion’s job responsibilities at the University of Tennessee include providing education regarding
low and high risk obstetrics to staff nurses in West Tennessee community hospitals. For more than 20 years Ms. Cashion has taught obstetric nursing in the clinical setting (mostly in Labor and Delivery) for students at Northwest Mississippi Community College in Senatobia, Mississippi, and Union University in Germantown, Tennessee.
Ms. Cashion has been an active AWHONN member, holding office at both the local and state levels. She also has served as an officer and board member of the Tennessee Perinatal Association and as an active volunteer for the Tennessee chapter, March of Dimes Birth Defects Foundation.
Ms. Cashion has contributed many chapters to maternity nursing textbooks over the years. She also
coauthored a series of Virtual Clinical Excursions workbooks to accompany six obstetric nursing textbooks published by Elsevier. More recently she served as one of the authors for Maternity & Women’s Health Care (10th edition), and Clinical Companion for Maternity & Newborn Nursing (2nd edition), and as an associate editor for Maternal Child Nursing Care (5th edition).

Kathryn Rhodes Alden is Clinical Associate Professor, University of North Carolina at Chapel Hill School of Nursing. She received a BSN from the University of North Carolina at Charlotte, an MSN from the University of North Carolina at Chapel Hill, and a doctorate in adult education from North Carolina State University.
Dr. Alden has extensive experience as a nursing educator, having served on the faculty at the University
of North Carolina at Charlotte and the University of North Carolina at Chapel Hill. Dr. Alden has clinical experience in pediatrics, pediatric intensive care, and neonatal intensive care. She is also experienced in home health care, having provided nursing care to pediatric and obstetric clients. She has worked as a nursing administrator and coordinator of quality improvement. As a certified lactation consultant, Dr. Alden has provided inpatient and outpatient care for breastfeeding mothers and infants and she has taught prenatal breastfeeding classes to expectant parents. She has taught continuing education courses on breastfeeding throughout North Carolina.
For the past 25 years as an educator for baccalaureate nursing students at UNC-Chapel Hill School of
Nursing, Dr. Alden has taught in maternal-newborn nursing courses, providing both classroom and clinical instruction. Dr. Alden coordinates and leads the academic counseling program, providing assistance to students and to faculty. She is actively involved in the leadership of the undergraduate nursing program as member and former chair of the Baccalaureate Executive Committee.
She has received numerous awards for excellence in nursing education at UNC, being recognized for
clinical and classroom teaching expertise as well as for academic counseling. Dr. Alden was selected for the Great 100 Nurses in North Carolina in 2008.
Dr. Alden was an early adopter of high-fidelity simulation and has been instrumental in the use of this
instructional strategy at UNC-Chapel Hill School of Nursing. She is actively involved in interprofessional collaboration with faculty from the UNC schools of Medicine and Pharmacy to offer obstetric and neonatal simulation learning activities to undergraduate nursing students, pharmacy students, and medical students in obstetrics and pediatrics. She has created numerous simulation scenarios including obstetric simulation cases for Elsevier. She has coauthored chapters on high-fidelity simulation and patient safety in publications by the Agency for Healthcare Research and Quality (AHRQ) and the NLN. Dr. Alden is an active member of AWHONN and the International Nursing Association for Clinical Simulation and Learning (INACSL).
Dr. Alden has authored numerous chapters on a variety of topics in maternity texts for Elsevier. She is
associate editor for Maternal Child Nursing Care (5th edition) and Maternity Nursing (8th edition).

Ellen F. Olshansky is Professor in the Program in Nursing Science at the University of California, Irvine, and served as its founding director from 2007 to 2014. Under her leadership UC-Irvine initiated the BSN program, followed by the approval and initiation of both the MS and PhD degrees in nursing science. She is the founder of the UCI Nursing Science Center for the Advancement of Women’s Health. Dr. Olshansky earned a BA in Social Work from the University of California, Berkeley, and a BS, MS, and PhD from the University of California, San Francisco School of Nursing. She was a faculty member at the schools of nursing at the Oregon Health Sciences University, University of Washington, Duquesne University, and the University of Pittsburgh before taking her current position at the UC-Irvine. She is a fellow in the American Academy of Nursing, served as co-chair of its Expert Panel on Women’s Health, and is a member of its Board of Directors. She is also a fellow in the Western Academy of Nursing. Dr. Olshansky also serves as director of the Community Engagement Unit of the UC-Irvine Institute for Clinical and Translational Science, funded by a National Institutes of Health (NIH) Clinical Translational Science Award. Through this position she engages community members in community-based participatory research, encouraging collaborative research between university faculty and community organizations. She has expertise in qualitative research and community-based participatory research. Dr. Olshansky is a women’s health nurse practitioner, certified through the National Certification Corporation (WHNP-BC). Her research has focused on women’s health across the life span, with a focus on reproductive health. Dr. Olshansky recently became a certified Integrative Nurse Wellness Coach, having completed the Integrative Nurse Coach Certification Program through the International Nurse Coach Association and successfully completing the certification exam through the American Holistic Nurses Credentialing Corporation (NC-BC). She is focused on working with people within their own communities to promote and maintain wellness. She is one of the founders of the Orange County Women’s Health Project, which works in collaboration with the UCI Nursing Science Center for the Advancement of Women’s Health. The purpose is to promote women’s health and wellness in Orange County, California, including holding annual women’s health policy summits. She recently completed a 10-year term as editor of the Journal of Professional Nursing, the official journal of the American Association of Colleges of Nursing. She has published extensively in numerous nursing and other health-related journals as well as authored many book chapters and editorials.

Women’s health care encompasses reproductive health care and the unique physical, psychologic, and social needs of women throughout their life span. The specialties of women’s health and maternity nursing offer challenges and opportunities. Nurses are challenged to assimilate knowledge and develop the technical and critical thinking skills needed to be reflective practitioners. Each woman, with her individual needs that must be identified and met, presents a challenge. However, the opportunities are sufficiently extraordinary to make this one of the most fulfilling specialties of nursing practice.
The goal of nursing education is to prepare today’s students to meet the challenges of tomorrow. This
preparation must extend beyond mastery of facts and skills. Nurses must be able to provide safe, quality, client-centered care through the combination of clinical reasoning skills, technical competence, and compassionate caring. They must address the physiologic as well as the psychosocial needs of their clients. They must look beyond the condition and see the woman as an individual with distinctive needs. Yet they must consider her needs in the context of family-centered care, realizing and acknowledging the influence and involvement of family members and significant others. Above all, nurses must strive to improve practice on the basis of sound evidence-based information. In a time of dwindling financial resources for health care, nurses can use evidence-based practice to produce measurable outcomes that can validate their unique and necessary role in the health care delivery system.
Maternity & Women’s Health Care was designed to provide students with accurate and up-to-date
information so that they can develop the knowledge and skills needed to become clinically competent, to think critically, and to attain the necessary sensitivity to become caring nurses. Maternity & Women’s Health Care has been a leading maternity nursing text since it was first published in 1977. We are proud of the continued support this text has received. With this eleventh edition we have a responsibility to continue this leading tradition.
This edition has been revised and refined in response to comments and suggestions from educators,
clinicians, and students. It includes the most accurate, current, and clinically relevant information available. We have had the assistance of expert faculty, nurse clinicians, and specialists from other health disciplines who authored, reviewed, and revised the text. Many exciting updates and additions will be noted throughout the book; they demonstrate the various dimensions of women’s health care and areas of rapid and complex changes such as genetics, fetal assessment, and alternative therapies. However, we have retained the underlying philosophy that has been the strength of previous editions: our belief that pregnancy and childbirth and developmental changes in a woman’s life are natural processes. We have also retained a base in physiology and a strong, integrated focus on the family and on evidence-based practice.
The text is also used as a reference for the practicing nurse. The most recent recommendations based on
evidence from research and clinical experts have been included from professional organizations such as the Association of Women’s Health, Obstetric and Neonatal Nurses; the National Association of Neonatal Nurses; the American College of Obstetricians and Gynecologists; the American Academy of Pediatrics; the American Diabetes Association; the Centers for Disease Control and Prevention; and the U.S. Preventive Health Services Task Force. The text can be used to prepare for certification courses and for review in graduate programs of study. The text and its electronic resources would be an excellent reference on the nursing unit.
Professional nursing practice continues to evolve and adapt to society’s changing health priorities. The everchanging health care delivery system offers new opportunities for nurses to alter the practice of maternity and women’s health nursing and to improve the way care is given. Consumers of maternity and women’s health care vary in age, ethnicity, culture, language, social status, marital status, sexual preference, and family configurations. They seek care from obstetricians, gynecologists, family practice physicians, nursemidwives, nurse practitioners, nurses, and other health care providers in a variety of health care settings, including the home. Increasingly, many are self-treating, accessing web-based information, and using a variety of alternative and complementary therapies.
Nursing education must reflect these changes. Clinical education must be planned to offer students a
variety of maternity and women’s health care experiences in settings that include hospitals and birth
centers, the home health setting, clinics and private physician offices, shelters for the homeless or women in need of protection, in prisons, and in other community-based settings. Advances in nursing education include the increased use of simulation learning activities. Simulation laboratories have emerged in schools of nursing and in health care institutions to provide students and staff with opportunities to engage in care of clients in focused, challenging situations while in the safety of a controlled environment. Simulation experiences offer students in maternity and women’s health courses opportunities that are otherwise unavailable due to shrinking opportunities for clinical placements, decreased clinical time, and increased numbers of students in clinical rotations.
Today’s nursing students are challenged to learn more than ever and often in less time than their
predecessors. Students are diverse. They may be new high school graduates, college students, or older
adults with families. They may be male or female. They may have college degrees in other fields and be
interested in changing careers. They may represent various cultures; English may not be their first language.
Students may be enrolled in associate degree or diploma programs, in baccalaureate or accelerated
baccalaureate nursing programs, or in entry level master’s programs. This eleventh edition, with its
accompanying teaching and learning package, has been revised to meet these changing needs. Each chapter has been reviewed by a specialist to improve readability and comprehension, especially by a diverse student population. Focused content is presented in a clearly written and easily read manner while retaining the comprehensiveness of previous editions. The text can be used by all levels of nursing education, and in courses of varying lengths.
Health care today emphasizes wellness and health promotion. This focus is an integral part of our
philosophy. Likewise the developmental changes a woman experiences throughout her life are considered natural and normal. In women’s health care, the goal is promotion of wellness for the woman through knowledge of her body and its normal functioning throughout her life span, while developing an awareness of conditions that require professional intervention. The unit on women’s health care emphasizes the wellness aspect of care but also includes information about common gynecologic problems as well as breast and gynecologic cancers. This unit has been placed before the units on pregnancy because many of the aspects of assessment and care can be applied to later chapters.
Pregnancy and birth are also part of a natural developmental process. We believe that students need to
thoroughly understand and recognize the normal processes before they can identify complications and
comprehend their implications for care. We present the entire normal childbearing cycle before discussing potential complications.
In this edition of Maternity & Women’s Health Care, there is expanded and enhanced content related to the risks associated with obesity as it relates to women’s health, pregnancy, and neonatal outcomes. In relevant chapters throughout the book, this content is addressed, based on the most current evidence-based information from the medical and nursing literature.
Readers will note that throughout the text, the authors use different terms to describe various racial and
ethnic groups. Whenever statistical data are described, the terms in the reference are used, for instance, non-Hispanic black, non-Hispanic white, and Hispanic. When discussing individual clients or population groups and their health beliefs, the more commonly used terms are used, for instance, Latina or Hispanic, Caucasian, African-American, and Asian.
The eleventh edition features a contemporary design and spacious presentation. Students will find that the logical, easy-to-follow headings and attractive full-color design highlight important content and increase visual appeal. More than 450 color photographs (many of them new) and drawings throughout the text illustrate important concepts and techniques to further enhance comprehension. Each chapter begins with a list of Learning Objectives designed to focus students’ attention on the important content to be mastered. Key Terms that alert students to new vocabulary are in blue, defined within the chapter, and included in a glossary at the end of the book. Each chapter ends with Key Points that summarize important content. Community Activity exercises are included in most chapters to provide opportunities for students to increase their knowledge of community resources. Clinical Reasoning case studies are integrated to guide students in applying their knowledge and increasing their ability to think and reflect critically about maternity and women’s health care issues. References have been updated significantly, with most citations being less than 5 years old and all chapters having citations within 1 year of publication. An expanded Table of Contents and Index make it easier for readers to locate exactly the information they are seeking. More of the additional outstanding features follow:
• Care Management is used as the consistent framework throughout nursing care chapters to discuss
assessment, medical and surgical management, and more specifically, the nursing care related to each topic.
• Nursing Care Plans help students apply the nursing process in the clinical setting and use NANDAapproved nursing diagnoses, describe expected outcomes for client care, provide rationales for interventions, and include evaluation of care.
• Teaching for Self-Management boxes emphasize guidelines for the client to practice self-care and provide information to help students transfer learning from the hospital to the home setting.
• Emergency boxes alert students to the signs and symptoms of various emergency situations and provide interventions for immediate implementation.
• Signs of Potential Complications boxes alert students to signs and symptoms of potential problems and are included in chapters that cover uncomplicated pregnancy and birth.
• Nursing Alert and Safety Alert boxes and new Medication Alert boxes highlight critical information.
• Evidence-Based Practice is incorporated throughout in new boxes that integrate findings from several studies on selected clinical practices and changing practice; Quality and Safety Education for Nursing (QSEN) competencies are illustrated in these boxes. In addition, research findings summarized in The Cochrane Pregnancy and Childbirth Database and other resources for evidence-based practices that confirm effective practices or identify practices that have unknown, ineffective, or harmful effects are integrated throughout the text.
• Cultural Considerations boxes describe beliefs and practices about pregnancy, childbirth, parenting, and women’s health concerns and the importance of understanding cultural variations when providing care.
• Legal Tips are integrated throughout to provide students with relevant information to deal with these
important areas in the context of maternity and women’s health nursing.
• Medication Guide boxes include key information about medications used in maternity and women’s
health care, including their indications, adverse effects, and nursing considerations.
The eleventh edition of Maternity & Women’s Health Care comprises eight units organized to enhance
understanding and learning and to facilitate easy retrieval of information.
Unit One, Introduction to Maternity & Women’s Health Care, begins with an overview of contemporary issues in maternity and women’s health nursing practice. Chapter 1 includes a section on historic milestones in maternity, women’s health, and neonatal care and provides an overview of important therapies that can be used instead of or in addition to traditional techniques used in maternity and women’s health care.
Chapter 2 addresses the community as a unit of care, incorporating family theory, cultural aspects of care, and home care in relation to maternity and women’s health nursing. Chapter 3 provides essential discussion about genetics in relation to maternity and women’s health care.
Unit Two, Women’s Health, is a thoroughly revised unit on women’s health. Eight chapters discuss
health promotion, screening, and physical assessment, and then present common reproductive concerns.
The chapter on assessment and health promotion incorporates normal anatomy and physiology of the
female reproductive system and integrates health promotion for common women’s health problems. There are separate chapters on reproductive problems and concerns, sexually transmitted infections and other infections, contraception and abortion, infertility, violence, problems of the breast, and structural disorders and neoplasms of the female reproductive system.
Unit Three, Pregnancy, describes nursing care of the woman and her family from conception through
preparation for birth. Nursing care during pregnancy includes both physiologic and psychologic aspects of care, as well as information on preparation for birth. A separate chapter on maternal and fetal nutrition emphasizes the important aspects of care, highlights cultural variations in diet, and stresses the importance of early recognition and management of nutritional problems.
Unit Four, Childbirth, focuses on collaborative care among physicians, nurse-midwives, nurses, and
women and their families during the processes of labor and birth. Separate chapters deal with the nurse’s role in maximizing comfort during labor and birth, and fetal monitoring, both of which have been updated significantly. All four chapters familiarize students with current childbirth practices and focus on evidencebased interventions to support and educate the woman and her family.
Unit Five, Postpartum, deals with a time of profound change for the entire family. Physiologic changes
and nursing care based on the changes are addressed. The mother requires both physical and emotional
support as she adjusts to her new role. The chapter on transition to parenthood discusses family dynamics in response to the birth of a child and describes ways nurses can facilitate parent-infant adjustment. Anticipatory guidance for the first few weeks at home and home follow-up care are addressed.
Unit Six, The Newborn, has been updated and addresses physiologic adaptations of the newborn and
assessment and care of the newborn. Information on the nutritional needs of the newborn and nursing care associated with breastfeeding and formula feeding are highlighted in a separate chapter.
Unit Seven, Complications of Pregnancy, discusses conditions that place the woman, fetus, infant, and
family at risk. This unit has been revised and updated and includes a chapter on assessment of the high risk pregnancy and eight other chapters covering specific pregnancy complications including hypertensive disorders, antepartal hemorrhagic disorders, endocrine and metabolic problems, medical-surgical problems, mental health problems and substance abuse, labor and birth complications, and postpartum complications.
Care management focuses on achieving the best possible outcomes, as well as supporting the woman and family when expectations are not met.
Unit Eight, Newborn Complications, describes the nursing care for high risk newborns, emphasizing the care of the preterm infant. There is enhanced content on care of late preterm infants in this edition. It addresses the most common acquired conditions of the neonate as well as hematologic disorders and
congenital anomalies. All chapters have been revised and updated. A separate chapter on loss and grief
discusses care of the family experiencing a fetal or neonatal loss.
Teaching/Learning Package
Evolve, for Students: Evolve is an innovative website that provides a wealth of content, resources, and stateof-the-art information on maternity nursing. Learning resources for students include Case Studies, Content Updates, Printable Key Points, Nursing Skills, and NCLEX-Style Review Questions.
Simulation Learning System (SLS): The SLS is an online toolkit that helps instructors and facilitators
effectively incorporate medium- to high-fidelity simulation into their nursing curriculum. Detailed patient scenarios promote and enhance the clinical decision-making skills of students at all levels. The SLS provides detailed instructions for preparation and implementation of the simulation experience, debriefing questions that encourage critical thinking, and learning resources to reinforce student comprehension. Each scenario in the SLS complements the textbook content and helps bridge the gap between lectures and clinical practice. The SLS provides the perfect environment for students to practice what they are learning in the text for a true-to-life, hands-on learning experience.
Study Guide: This comprehensive and challenging study aid presents a variety of questions to enhance
learning of key concepts and content from the text. Multiple-choice and matching questions are included, as well as Critical Thinking Case Studies. Answers for all questions are included at the back of the study guide.
Virtual Clinical Excursions: Virtual Hospital and Workbook Companion: A Virtual Hospital and
workbook package has been developed as a clinical experience to expand student opportunities for critical thinking. This package guides the student through a virtual clinical environment and helps the user apply textbook content to virtual clients in that environment. Case studies are presented that allow students to use this textbook as a reference to assess, diagnose, plan, implement, and evaluate “real” clients using clinical scenarios. The state-of-the-art technologies reflected in this virtual hospital demonstrate cutting-edge learning opportunities for students and facilitate knowledge retention of the information found in the textbook. The clinical simulations and workbook represent the next generation of research-based learning tools that promote critical thinking and meaningful learning.
Evolve, for Instructors includes these teaching resources:
• Test Bank in ExamView format contains more than 1000 NCLEX-style test items, including alternate format questions. An answer key with page references to the text, rationales, and NCLEX-style coding is included.
• TEACH for Nurses includes teaching strategies; in-class case studies; and links to animations, nursing
skills, and nursing curriculum standards such as QSEN, concepts, and BSN Essentials.
• Image Collection, containing more than 700 full-color illustrations and photographs from the text, helps instructors develop presentations and explain key concepts.
• PowerPoint slides, with lecture notes for each chapter of the text, assist in presenting materials in the
classroom. Case Studies and Audience Response Questions for i-clicker are included.
• A Curriculum Guide that includes a proposed class schedule and reading assignments for courses of
varying lengths is provided. This gives educators suggestions for using the text in the most essential
manner or in a more comprehensive way.

Table of Contents
Cover image
Title page
About the Authors
UNIT ONE. Introduction to Maternity & Women’s Health Care
Chapter 1. 21st Century Maternity and Women’s Health Nursing
Advances in the Care of Women and Infants
Efforts to Reduce Health Disparities
Contemporary Issues and Trends
Trends in Fertility and Birth Rate
Regionalization of Perinatal Health Care Services
High-Technology Care
Community-Based Care
Childbirth Practices
Involving Consumers and Promoting Self-Management
International Concerns
Women’s Health
The Future of Nursing
Trends in Nursing Practice
Standards of Practice and Legal Issues in Provision of Care
Ethical Issues in Perinatal Nursing and Women’s Health Care
Research in Perinatal Nursing and Women’s Health Care
Key Points
Chapter 2. Community Care: The Family and Culture
Introduction to Family, Culture, Community, and Home Care
The Family in Cultural and Community Context
Theoretic Approaches to Understanding Families
The Family in a Cultural Context
Developing Cultural Competence
Community Health Promotion
Assessing the Community
Home Care in the Community
Care Management
Key Points
Chapter 3. Nursing and Genomics
Nursing Expertise in Genetics and Genomics
Human Genome Project and Implications for Clinical Practice
Clinical Genetics
Cancer Genomics
Genetic Counseling
Future Promise of Genetics
Key Points
UNIT TWO. Women’s Health
Chapter 4. Assessment and Health Promotion
Female Reproductive System
Menstruation and Menopause
Sexual Response
Reasons for Entering the Health Care System
Barriers to Entering the Health Care System
Health Risks to Women
Health Assessment
Anticipatory Guidance for Health Promotion and Illness Prevention
Key Points
Chapter 5. Violence Against Women
Intimate Partner Violence
Care Management
Sexual Violence
Sex Trafficking
Key Points
Chapter 6. Reproductive System Concerns
Common Menstrual Disorders
Care Management
Care Management
Key Points
Chapter 7. Sexually Transmitted and Other Infections
Sexually Transmitted Bacterial Infections
Sexually Transmitted Viral Infections
Vaginal Infections
Maternal and Fetal Effects of Sexually Transmitted Infections
Care Management
Infection Control
Key Points
Chapter 8. Contraception and Abortion
Care Management
Methods of Contraception
Induced Abortion
Care Management
Key Points
Chapter 9. Infertility
Factors Associated with Infertility
Care Management
Key Points
Chapter 10. Problems of the Breast
Benign Conditions of the Breast
Care Management for Women with Benign Breast Conditions
Malignant Conditions of the Breast
Care Management for Women with Breast Cancer
Key Points
Chapter 11. Structural Disorders and Neoplasms of the Reproductive System
Structural Disorders of the Uterus and Vagina
Benign Neoplasms
Care Management
Malignant Neoplasms
Care Management
Care Management
UNIT THREE. Pregnancy
Chapter 12. Conception and Fetal Development
Embryo and Fetus
Nongenetic Factors Influencing Development
Key Points
Chapter 13. Anatomy and Physiology of Pregnancy
Gravidity and Parity
Pregnancy Tests
Adaptations to Pregnancy
Key Points
Chapter 14. Nursing Care of the Family During Pregnancy
Diagnosis of Pregnancy
Adaptation to Pregnancy
Care Management
Variations in Prenatal Care
Perinatal Education
Perinatal Care Choices
Key Points
Chapter 15. Maternal and Fetal Nutrition
Nutrient Needs Before Conception
Nutrient Needs During Pregnancy
Care Management
Key Points
UNIT FOUR. Childbirth
Chapter 16. Labor and Birth Processes
Factors Affecting Labor
Process of Labor
Physiologic Adaptation to Labor
Key Points
Chapter 17. Maximizing Comfort for the Laboring Woman
Pain During Labor and Birth
Factors Influencing Pain Response
Nonpharmacologic Pain Management
Pharmacologic Pain Management
Care Management
Key Points
Chapter 18. Fetal Assessment During Labor
Basis for Monitoring
Monitoring Techniques
Fetal Heart Rate Patterns
Care Management
Other Methods of Assessment and Intervention
Client and Family Teaching
Key Points
Chapter 19. Nursing Care of the Family During Labor and Birth
First Stage of Labor
Care Management
Second Stage of Labor
Care Management
Third Stage of Labor
Care Management
Fourth Stage of Labor
Care Management
Key Points
UNIT FIVE. Postpartum
Chapter 20. Postpartum Physiologic Changes
Reproductive System and Associated Structures
Endocrine System
Urinary System
Gastrointestinal System
Cardiovascular System
Respiratory System
Neurologic System
Musculoskeletal System
Integumentary System
Immune System
Key Points
Chapter 21. Nursing Care of the Family During the Postpartum Period
Transfer from the Recovery Area
Planning for Discharge
Care Management: Physical Needs
Care Management: Psychosocial Needs
Discharge Teaching
Key Points
Chapter 22. Transition to Parenthood
Parental Attachment, Bonding, and Acquaintance
Parent-Infant Contact
Communication Between Parent and Infant
Parental Role After Birth
Diversity in Transitions to Parenthood
Parental Sensory Impairment
Sibling Adaptation
Grandparent Adaptation
Care Management
Key Points
UNIT SIX. The Newborn
Chapter 23. Physiologic and Behavioral Adaptations of the Newborn
Transition to Extrauterine Life
Key Points
Chapter 24. Nursing Care of the Newborn and Family
Care Management: Birth Through the First 2 Hours
Care Management: from 2 Hours after Birth Until Discharge
Key Points
Chapter 25. Newborn Nutrition and Feeding
Recommended Infant Nutrition
Choosing an Infant Feeding Method
Cultural Influences on Infant Feeding
Nutrient Needs
Anatomy and Physiology of Lactation
Care Management
Indicators of Effective Breastfeeding
Formula Feeding
Key Points
UNIT SEVEN. Complications of Pregnancy
Chapter 26. Assessment of High Risk Pregnancy
Assessment of Risk Factors
Antepartum Testing
Biophysical Assessment
Biochemical Assessment
Fetal Care Centers
Antepartum Assessment Using Electronic Fetal Monitoring
Psychologic Considerations Related to High Risk Pregnancy
Nurses’ Role in Assessment and Management of the High Risk Pregnancy
Key Points
Chapter 27. Hypertensive Disorders
Significance and Incidence
Care Management
Key Points
Chapter 28. Hemorrhagic Disorders
Early Pregnancy Bleeding
Care Management
Care Management
Care Management
Care Management
Late Pregnancy Bleeding
Care Management
Care Management
Key Points
Chapter 29. Endocrine and Metabolic Disorders
Diabetes Mellitus
Pregestational Diabetes Mellitus
Care Management
Gestational Diabetes Mellitus
Hyperemesis Gravidarum
Care Management
Thyroid Disorders
Maternal Phenylketonuria
Key Points
Chapter 30. Medical-Surgical Disorders
Cardiovascular Disorders
Care Management
Other Medical Disorders in Pregnancy
Surgery During Pregnancy
Care Management
Trauma During Pregnancy
Care Management
Key Points
Chapter 31. Mental Health Disorders and Substance Abuse
Mental Health Disorders During Pregnancy
Anxiety Disorders
Postpartum Mood Disorders
Perinatal Substance Abuse
Key Points
Chapter 32. Labor and Birth Complications
Preterm Labor and Birth
Care Management
Premature Rupture of Membranes
Care Management
Postterm Pregnancy, Labor, and Birth
Care Management
Dysfunctional Labor (Dystocia)
Care Management
Care Management
Obstetric Procedures
Care Management
Obstetric Emergencies
Care Management
Care Management
Care Management
Care Management
Care Management
Key Points
Chapter 33. Postpartum Complications
Postpartum Hemorrhage
Care Management
Hemorrhagic (Hypovolemic) Shock
Venous Thromboembolic Disorders
Postpartum Infections
Care Management
Key Points
UNIT EIGHT. Newborn Complications
Chapter 34. Nursing Care of the High Risk Newborn
Care Management
Key Points
Chapter 35. Acquired Problems of the Newborn
Birth Trauma
Care Management
Infants of Mothers with Diabetes
Neonatal Infections
Care Management
Substance Abuse
Care Management
Key Points
Chapter 36. Hemolytic Disorders and Congenital Anomalies
Care Management
Congenital Anomalies
Respiratory System Anomalies
Gastrointestinal System Anomalies
Musculoskeletal System Anomalies
Genitourinary System Anomalies
Inborn Errors of Metabolism
Care Management
Key Points
Chapter 37. Perinatal Loss, Bereavement, and Grief
Loss, Bereavement, and Grief: Basic Concepts and Theories
Types of Losses Associated with Pregnancy
Miles’s Model of Parental Grief Responses
Family Aspects of Grief
Care Management
When a Loss is Diagnosed: Helping the Woman and her Family in the Aftermath
Special Circumstances
Key Points

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Pathology–Examinations, questions, etc, Pathology–Examination Questions. QZ 18.2 D161pa 2009]

Ivan Damjanov

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Book Details
 522 p
 File Size 
 3,686 KB
 File Type
 PDF format
 2009 by Mosby, Inc.,
 an affiliate of Elsevier Inc.

Ivan Damjanov, MD, PhD
Professor of Pathology, Department of Pathology and Laboratory Medicine, University of Kansas School of Medicine, Kansas City, Kansas
Snjezˇana Dotlic´, MD
Staff Pathologist, Clinical Hospital Center Zagreb, Zagreb, Croatia
Bruce A. Fenderson, PhD
Professor of Pathology, Department of Pathology, Anatomy, and Cell Biology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
Zoran Gatalica, MD, DSc
Professor of Pathology, Department of Pathology, Creighton University School of Medicine, Omaha, Nebraska
Pe´ter P. Molna´r, MD, DSc
Professor of Pathology, Department of Pathology, University of Debrecen School of Medicine, Medical and Health Sciences Center, Debrecen, Hungary
Anamarija Morovic´, MD
Clinical Instructor, Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
Marin Nola, MD, PhD
Associate Professor of Pathology, Department of Pathology, University of Zagreb School of Medicine, Zagreb, Croatia

This book was prepared for medical students in the hope that they will use it as a study guide
and a source of succinct information complementing other sources that have been made
available to them by their professors. I also hope that the book will help them prepare for
seminars and discussion groups, both in the standard medical school setting and in the new
problem-based curriculum. Finally, I hope that some students will use it while reviewing the
pathology material for the board examinations.
During the past 30 years, I have taught pathology in several medical schools and have
thus had the privilege of interacting with many medical students. Many of them, assuming
that I have gathered some experience in teaching, used to ask me how to study pathology.
My usual answer was this: Try to develop your own style, find out what is the most efficient
way of studying (i.e., discover whatever works best for you), and then apply this approach
systematically by using all means that you have at hand.
Over the years, I learned that some medical students profit most from lectures, others from
books, whereas still others need both the books and the lectures. Some students like to use
atlases, whereas others like to study the pictures from the computers. Some students love to
study microscopy slides and autopsy material, whereas others think that such exercises are a
waste of time. In other words, there are no secret ways to learn pathology or, for that matter,
anything else.
If there are no secrets to be offered on how to study pathology, what would then be a good
reason to read a book titled Pathology Secrets? My answer to the astute student asking this
question is simple: This book might help you see more clearly the ‘‘secret’’ pearls of wisdom
contained in the ‘‘big books’’ (i.e., the prescribed textbooks of pathology), help you tackle the
material presented during the course in various other formats, and help you concentrate on
the ‘‘important’’ topics. It could also help you understand better the basic topics of pathology
by presenting them from a different angle than you have seen than in the standard textbooks.
In addition, because many questions in this book are answered in a concise, bulleted form, I
thought that Pathology Secrets could help you acquire the essential concepts of pathology more
easily and in a more systematic way than if you had to compile such an outline on your own.
As an added bonus, I have also included a few mnemonics here and there and a few other
tricks to help you memorize for the long term the important facts, information you could use
later in the clinics.
This book contains close to 2000 questions dealing with the most important topics of
pathology. Almost all these questions were classroom tested; that is, most of these questions
were used in discussions with medical students. The answers provided to these questions
are short and in a format that I would expect from my students attending seminars and
discussion groups or in written essay–type examinations. I hope that my presentation of
these answers conveys a clear message: Always cover the main topics; ignore the trivia and
unnecessary details. Be systematic! Be concise! And remember: You do not have to know
everything; nobody knows everything.
At the end of this Preface, I would like to acknowledge the input of all those medical
students who have, in one form or another, helped me develop the Socratic course of
pathology outlined here, formulate the questions, and summarize the answers. I must also
acknowledge the contributions of my colleagues, or former students and collaborators from
other universities in the United States and Europe, who helped me put this book together.
—Ivan Damjanov, MD, PhD

These secrets are 100 of the top board alerts. They summarize the concepts,
principles, and most salient details of pathology.

1. The cell volume depends on the proper function of the cell membrane, which remains
semipermeable only if properly energized with adenosine triphosphate (ATP).

2. Cell injury is accompanied by an increased concentration of free calcium ions in the hyaloplasm.

3. Cell death causes distinctive nuclear changes, including pyknosis, karyolysis, and karyorrhexis.

4. Necrosis is death of cells or tissues caused most often by ischemia or the action of toxic
substances and infectious pathogens.

5. Although apoptosis is also called programmed cell death, it can be also induced by exogenous
factors, such as viruses or drugs.

6. Hyperplasia is an increase in the size of a tissue or organ resulting from an increased number of
constituent cells, whereas hypertrophy entails enlargement of individual cells.

7. Inflammation involves a vascular, a cellular, and a humoral response.

8. Mediators of inflammation are produced by many cells, including endothelial cells and
inflammatory cells, and the liver, which is the main source of plasma proteins.

9. Hageman factor (clotting factor XII) plays a pivotal role in activating the kinin, complement,
clotting, and fibrinolytic systems.

10. Cytokines are multifunctional polypeptides that modulate the function of other cells.

11. Polymorphonuclear leukocytes are the principal cells of acute inflammation, whereas
lymphocytes, macrophages, and plasma cells participate in chronic inflammation.

12. Edema is accumulation of fluid in the interstitial spaces and the body cavities.

13. Thrombosis is a pathologic form of coagulation of circulating blood inside intact vascular

14. The Virchow triad includes three factors that promote thrombosis: changes in the vessel wall,
changes in blood flow, and changes in the composition of blood.

15. Thromboembolism is the most common form of embolism.

16. Disseminated intravascular coagulation is a form of thrombosis in small blood vessels
associated with uncontrollable bleeding because of consumption of coagulation factors in

17. Infarct is an area of ischemic necrosis that is usually caused by occlusion of vessels or
hypoperfusion of tissues with blood.

18. Shock, a condition caused by hypoperfusion of tissues with blood, can be classified as
cardiogenic, hypovolemic, and distributive (related to vasodilatation).

19. Hypersensitivity reactions involve cell and tissue injury caused by antibodies or products of
activated T lymphocytes.

20. Autoimmune diseases are based on the immune reaction against self-antigens.

21. Acquired immunodeficiency syndrome (AIDS), an infectious disease caused by the human
immunodeficiency virus (HIV), is characterized by profound suppression of the immune system
and susceptibility to infections, neurologic disorders, and malignancies.

22. Cancer is a synonym for malignant tumors.

23. The main groups of malignant tumors are carcinomas, sarcomas, lymphomas, and gliomas.

24. Carcinogens are cancer-inducing factors that include physical forces, chemicals, viruses, and
endogenous oncogenes.

25. Reactions of the host to the tumor can be classified as local or systemic and include various
inflammatory, immune, hormonal, circulatory, and neural processes.

26. Teratogens are chemical, physical, or biological agents capable of inducing developmental
abnormalities in a fetus.

27. Down syndrome, the most common autosomal chromosomal abnormality, is characterized by
mental deficiency and characteristic facial and somatic features.

28. According to the laws of Mendelian genetics, single gene defects are inherited as autosomal
dominant, autosomal recessive, or sex-linked dominant or recessive traits.

29. Atherosclerosis is a multifactorial disease that predominantly affects older people, but it can be
accelerated by hypertension, hyperlipidemia, and smoking.

30. Arterial hypertension is a multifactorial disease of unknown etiology, but it can also be
secondary to renal, endocrine, vascular, and neurologic diseases.

31. Vasculitis, an inflammation of vessels, is most often immunologically mediated.

32. Aneurysms are localized dilatations of the arteries most often caused by atherosclerosis and

33. Cardiac failure may be caused by inherent heart disease or extracardiac causes, such as
pressure overload in hypertension or volume overload in renal water retention.

34. Coronary heart disease is the most common cause of cardiac failure and the most common
cause of death in the United States.

35. Myocardial infarction represents an area of myocardial cell necrosis caused by ischemia.

36. Arrhythmia is the most common complication of myocardial infarction.

37. Endocarditis is most often caused by bacteria.

38. Cardiomyopathy occurs in three forms known as dilatated, hypertrophic, and restrictive

39. Ventricular septal defect, the most common noncyanotic congenital heart disease, is
characterized by a left-to-right shunt.

40. Tetralogy of Fallot, the most common cyanotic congenital heart disease, includes four
pathologic findings: ventricular septal defect, overriding dextraposed aorta, pulmonary artery
stenosis, and right ventricular hypertrophy.

41. Hypochromic microcytic anemia is most often caused by iron deficiency and chronic blood loss.

42. Sickle cell anemia is a hereditary hemoglobinopathy caused by a mutation of the a-globin gene.

43. Lymphomas—malignant tumors of lymphoid cells—are most often of B-cell origin.

44. Leukemia is a malignancy of hematopoietic and lymphoid cells characterized by the appearance
of malignant cells in the circulation.

45. Multiple myeloma, a malignancy of plasma cells, is associated with lytic bone lesions and
monoclonal gammopathy.

46. Hodgkin disease, a form of lymph node malignancy characterized by the presence of Reed–
Sternberg cells, occurs in several histologic forms.

47. Atelectasis is incomplete expansion of the lungs or the collapse of previously inflated lung

48. Adult respiratory distress syndrome (ARDS) is caused by diffuse alveolar damage resulting
from injury of endothelial cells or pneumocytes forming the alveolar–capillary units.

49. Chronic obstructive pulmonary disease includes several diseases, the most important of which
are emphysema and chronic bronchitis.

50. Bronchial asthma is a chronic relapsing inflammatory obstructive lung disease presenting with
hyperreactivity of airways and periodic bronchospasm.

51. Acute pneumonia is an inflammation of lungs usually caused by viruses or bacteria.

52. Pneumoconioses are interstitial lung diseases caused by inhaled particles such as coal, silica, or

53. Most lung cancers originate from the epithelium of the bronchi and are related to smoking.

54. Esophagitis is most often caused by gastroesophageal reflux disease (GERD).

55. Atrophic gastritis, the most common form of gastritis, is most often caused by Helicobacter

56. Peptic ulcers are prone to bleeding.

57. Carcinomas of the esophagus and stomach have poor prognosis.

58. Diarrhea can be classified as osmotic, secretory, exudative, malabsorptive, and mixed.

59. Malabsorption syndrome is characterized by steatorrhea and deficiency of fat-soluble vitamins.

60. Inflammatory bowel disease includes Crohn disease and ulcerative colitis, which share some
features but also differ in many aspects.

61. Carcinoma of the large intestine is the third most common form of cancer and the third most
common cancer-related cause of death in the United States. It occurs most often in the
rectosigmoid area.

62. Jaundice can be classified as prehepatic (hemolytic), hepatic, and posthepatic (obstructive).

63. Cirrhosis is equivalent to end-stage liver disease characterized by loss of normal hepatic
architecture, fibrosis, and the formation of regenerating nodules.

64. Hepatitis is most often caused by viruses, drugs, or immune mechanisms.

65. Chronic alcoholism may cause three pathologic changes in the liver: fatty liver, alcoholic
hepatitis, and cirrhosis.

66. Alcohol and biliary disease account for 80% of all causes of acute pancreatitis.

67. Diabetes mellitus, a disease characterized by hyperglycemia, is caused by insulin deficiency or
tissue resistance to insulin, and it occurs in two main forms called type 1 and type 2.

68. Uremia is a set of clinical and laboratory findings found in patients with end-stage kidney

69. Glomerulonephritis is immunologically mediated in most instances.

70. Pyelonephritis is a bacterial kidney infection.

71. The most important tumors of the kidneys and the urinary tract are renal cell carcinoma,
transitional cell carcinoma, and Wilms tumor.

72. Testicular tumors are derived from germ cells in 90% of cases and belong to two groups:
seminomas and nonseminomatous germ cell tumors (NSGCTs).

73. Prostate carcinoma is the most common malignant tumor in males.

74. Carcinomas of the vulva, vagina, and cervix are linked to human papilloma virus (HPV) infection.

75. Endometrial adenocarcinoma is linked to hyperestrinism.

76. Leiomyomas are the most common benign tumors of the uterus.

77. Breast carcinoma is the most common malignant tumor in females.

78. Hyperthyroidism may be caused by autoimmune mechanisms (e.g., in Graves disease), tumors
(e.g., follicular adenomas), or hyperfunctioning goiters.

79. Hyperparathyroidism, most often caused by parathyroid adenoma, is characterized by

80. Hypofunction of adrenal glands is the cause of Addison disease, whereas hyperfunction causes
Cushing syndrome.

81. The three most important skin diseases caused by bacteria are impetigo, folliculitis, and acne.
82. Warts are caused by HPV infection.

83. Psoriasis is a common chronic skin disease of unknown etiology affecting 1% to 2% of the

84. Skin cancer is related to sun exposure.

85. Basal cell carcinoma of the skin, the most common malignant tumor, is only locally invasive and rarely metastasizes.

86. Pigmented skin lesions may be benign (such as freckles, lentigo, and nevus) or malignant (such
as malignant melanoma).

87. Osteoporosis is a form of osteopenia characterized by a loss of both calcium salts and organic
matrix of the bones (osteoid).

88. The two most important diseases of the joints are rheumatoid arthritis and osteoarthritis.

89. Osteosarcoma occurs most often in children and young people, whereas chondrosarcoma has
its peak incidence in adults.

90. Duchenne muscular dystrophy is the most common genetic muscle disease.

91. The most important immunologic diseases of the muscle are polymyositis and myasthenia

92. Rhabdomyosarcoma is a malignant tumor of striated muscle.

93. The most important forms of intracranial bleeding are intracerebral hemorrhage in
hypertension, subdural hematoma, subarachnoid hematoma, and epidural hematoma.

94. Infection of the brain and the meninges can occur through four main routes: vascular spread,
direct extension, ascending neural route, and penetrating wounds.

95. Tabes dorsalis is a spinal cord lesion caused by syphilis.

96. Multiple sclerosis is a demyelinating autoimmune disease characterized by a chronic relapsing
and remitting course.

97. Alzheimer’s disease, an old-age neurodegenerative disease of unknown etiology, is the most
common cause of dementia.

98. Most brain tumors are malignant.

99. Gliomas are malignant tumors of the central nervous system originating from astrocytes,
oligodendroglia cells, and ependymal cells.

100. Diabetic neuropathy is the most common peripheral nerve disease encountered in general


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