Exam 1 L&D 1.Describe key aspects of preconception care and counseling.

Preconception care and counseling: provides information that is needed to make decisions about their reproductive future. : can be provided as part of routine health examination such as premarital, employment, school and family planning. :guides couples on how to avoid unintended pregnancies, how to manage risk factors in their lives and their environment and how to identify healthy behaviors that promote the well-being of the women and potential fetus. 2.Document the GP or GTPAL given a clients obstetric history. Gravida-represents the number of pregnancy the woman has had, including present one Parity- is the number of pregnancy that have reached viability. First time pregnant twin mom would be G 1 P 1 G- gravidity number of pregnancy(including this one) T- term births beginning of week 38 of gestation to the end of week 42 of Gestation. P- Preterm birth that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation. A- abortion or miscarriage L- number of living children including preterm babies. 3.Calculate the EDB using Nagels Rule given a clients LMP. Clients LMP add 7 days and count forward 9 calendar months. 4. List presumptive, probable and positive signs of pregnancy and explain why they fit in the given category. Presumptive (those changes felt by the women e.g. amenorrhea, fatigue, Nausea and vomiting, breast changes) Breast changes- premenstrual changes, oral contraceptives Amenorrhea- stress, vigorous exercise, early menopause, endocrine problems, malnutrition. Nausea and vomiting- gastrointestinal virus, food poison. Urinary frequency- infection, pelvic tumors. Fatigue- stress, illness quickening- gas, peristalsis. Probable - (those changes observed by an examiner)

Goodell sign- softening of the cervix, a probable sign of pregnancy during the second month. ( pelvic congestion). Chadwick sign- violet color of vaginal mucus membrane that is visible from about 5th week of pregnancy. ( pelvic congestion) Hegar sign- softening of the lower uterine segment that is classified as a probable sign of pregnancy and that may be present during the second and 3rd months of pregnancy and is palpated during bimanual exam.(pelvic congestion) Positive result of pregnancy test( serum)- hydatidiform mole. Positive result of preg. Test (urine)- false + results may be caused by pelvic infection, tumors Braxton Hicks contraction( painless uterine contractions)- myomas, other tumors. Ballottement( move ability of a floating object such as fetus)- tumors, cervical polyps. Positive signs- directly attributed to the fetus and include the presence of a fetal heartbeat, fetal movement felt by someone other than mother and visual of the fetus with a technique such as US. 5. Discuss fetal development with particular emphasis on placenta and umbilical cord development, structure and function. Umbilical cord- during 5th week, the embryo has curved inward on itself from both ends, bringing the connecting stalk to the ventral side of the embryo. The connecting stalk becomes compressed from both sides by the amnion and forms the narrower umbilical cord. Two arteries carry blood away from the embryo to the chorionic villi and one vein returns blood to the embryo. A true knot is rare but false knots occur as folds or kinks in the cord and may jeopardize circulation to the fetus. Connective tissue called Whartons jelly prevents compression of the blood vessels and ensures continued nourishment of the embryo/fetus. Compression can occur if the cord lies between the fetal head and the maternal pelvis or is twisted around the fetal body. When the cord is wrapped around the fetal neck, it is called a nuchal cord. because the placenta develops from the chronic villi, the umbilical cord is usually located centrally. Placenta -structure- forms at implantation. A third layer develops into anchoring septa dividing into separate areas called cotyledons.- from here a complex system of fetal blood vessels forms. Each cotyledon is a functional unit. The whole structure is the placenta. By the end of 3rd week, embryonic blood is circulating between the embryo

and the chorionic villi. - in the intervillous spaces, maternal blood supplies O2 and nutrients to the embryonic capillaries in the villi. Waste products and CO2 diffuses into the maternal blood. structure of the placenta is completed by the 12th week. FUNTIONS- early functions is as an endocrine gland that produces four hormones necessary to maintain the pregnancy and support the embryo/ fetus. HCG- basis for pregnancy tests- preserves the function of the ovarian corpus luteum, ensuring the continued supply of estrogen and progesterone needed to maintain the pregnancy. Miscarriages occur is the corpus luteum stops functioning before the placenta is producing sufficient estrogen and progesterone. HCS-similar to a growth hormone and stimulates the maternal metabolism to supply nutrients needed for fetal growth. This hormone increases resistance to insulin, facilitates glucose transport across the placental membrane and stimulates breast development to prepare for lactation. The metabolic functions of the placenta are respiration, nutrition, excretion and storage. O2 diffuses from the maternal blood across the placenta membrane into the fetal blood and CO2 diffuses in the opposite direction- functions as lungs. 6. Discuss multi fetal pregnancies, considering dizgotic vs. monozygotic twins, the different development stages for formation of monozygotic twins and the resulting implications. Include incidence, familial/racial likelihood and significant difference in prognosis and care. Dizgotic twins - when 2 mature ova are produced in one cycle, both have the potential to be fertilized be separate sperm. Always 2 amnions, 2 chorions, and 2 placenta which may be fused. These dizgotic twins may be of same sex or different and genetically no more like than siblings born at different times. Occurs more often in AfricanAmerican women than Caucasian and least to Asian. Dizgotic twinning increases with maternal age up to 35 years with parity and with the use of fertility drugs. Monozygotic twins- identical twins develop from one fertilized ovum which then divides. They are of same sex and have same genotype. If division occurs soon after fertilization, 2 embryos, 2 amnions, 2 chorions, and 2 placenta. If between 4-8 days fertilization, there are 2 embryo, 2 amnions, 1chorion and 1 placenta. After 8th day - 2 embryo within a common amnion ,a chorion with one placenta. This often cause circulatory problems due to umbilical cords may be tangle together and one or both

fetuses may die. If division occurs very late cleavage may not be complete, and conjoined twins could result. Monozygotic twinning occurs 1 in 250 births. No association with race, heredity, maternal age, or parity. Fertility drugs increase the incidence of monozygotic twins. 7. Explain fetal circulation, identifying the 3 major shunts and their purpose; discuss umbilical circulation and the direction of flow for O2 and un-oxygenated blood. - first organ system to function in the developing human. - the fetal lungs do not function for respiratory gas exchange, so a special of circulatory pathway, the ductus arteriosus, bypass the lungs. Oxygen rich blood from the placenta flows rapidly through the umbilical vein into the fetal abdomen. -when the umbilical vein reaches the liver, it divides into 2 branches, 1 branch circulates some oxygenated blood through the liver. -most of the blood passes through the ductus venous into the inferior vena cava. There it mixes with the deoxygenated blood from the fetal legs and abdomen on its way to the right atrium. -most of this blood passes straight through the right atrium and through the foramen oval, an opening into the left atrium. There it mixes with the small amount of deoxygenated blood returning from the fetal lungs through the pulmonary vein. -the blood flow into the left ventricle and is squeezed out into the aorta, where the arteries supplying the heart, head, neck, and arms receive most of the oxygen rich blood. This pattern of supplying the highest levels of oxygen and nutrients to the head, neck, and arms enhances the cephalocaudal (headto-rump) development of the embryo/fetus. -Deoxygenated blood returning from the head and arms enters the right atrium through the superior vena cava. This blood is directed downward into the right ventricle, where it is squeezed into the pulmonary artery. The oxygen -poor blood flows through the abdominal aorta into the internal iliac arteries, where the umbilical arteries direct most of it back through the umbilical cord to the placenta. 8. Discuss the psychological experiences and task of pregnancy and postpartum. Describe normal early ambivalence and its expected healthy resolution; validate the lack of correlation with child rejection, neglect or abuse after birth. Explain the sequence: I am pregnant, I am going to have a baby, I am going to be a mother in terms of changing body image, recognizing self and fetus as separate beings, and preparing to

separate from/release the infant, negotiate the role change, and being parenting. Women of all ages use the month of pregnancy to adapt to the maternal role, a complex process of social and cognitive learning. Early in pregnancy, nothing seems to be happening and women may spend time sleeping secondary to the increase fatigue of this stage. With the perception of fetal movement in 2nd trimester the woman turns her attention inward to her pregnancy and to relationship with her mother and other woman who have been or who are pregnant. She moves gradually from being self contained and independent to being committed to a life long concern for another human being. -despite a general feeling of well-being, many women are surprised to experience emotional liability that is rapid and unpredictable changes in mood. -these swings in emotions increase sensitivity to others are disconcerting to the expected mother and those around her. -increase irritability, explosions of tears and anger and feelings of great joy and cheerfulness alternate apparently with little or no provocation. -AMBIVALENT FEELING- most woman have ambivalent feelings during pregnancy whether the pregnancy was intended or not. During pregnancy women may feel pleasure that they are fulfilling a lifelong dream but they also may feel great regret that life as they now know is ending . -intense feeling of ambivalence that persist through the 3rd trimester may indicate an unresolved conflict with the motherhood role. -after the birth of a healthy child memories of these ambivalent feeling usually are dismissed. If the child is born with a defect however a woman may look back at the times when she did not want the pregnancy and feel intensely guilty. I am pregnant- accept biological fact of pregnancy and incorporate the idea of a child into her body and self image. The child is viewed as part of herself, not a separate and unique being. (phase 1) I am going to have a baby- (phase 2) woman accepts the growing fetus as distinct from herself. Beginning of the mother-child relationship that involves not only caring but also responsibility. Attachment of a mother to her child is enhanced by experiencing a planned pregnancy and it increases when ultrasound examination and quickening confirm the reality of the fetus. I am going to be a mother-( phase 3)- the woman prepares realistically for the birth and parenting of the child. She defines the nature and characteristics of the child. She speculate about the childs sex, and

personality traits based on patterns of fetal activity. 9. Describe the emotional changes and experience of pregnancy including more rapidly alternating emotional extremes with higher highs and lower lows and discuss sources of mood swings in pregnancy. Explore pregnancy as an altered state of consciousness, with consideration for the distinctive quality of the inner experience and the opportunity for emotional growth and healing.

10. Teach the client the warning signs of possible complications in pregnancy according to trimester and explain what potential concern each presents. First trimester-severe vomiting- hyper emesis gravidarium Chills, fever - infection Burning on urination - infection Diarrhea infection Abd. Cramping; vag. Bleeding -miscarriage, ectopic pregnancy. Second and third trimester -Persistent, severe vomiting - hyper emesis gravid arum, hypertension, preeclampsia -Sudden discharge of fluid from vagina b4 37 wk- premature ROM -Vaginal bleeding, severe abd. Pain -miscarriage, placenta previa, abruptio placentae -Chills, fever, burning on urination, diarrhea- infection -Severe backache or flank pain - kidney infection or stones preterm labor. -Changes in fetal movt: absence of fetal movt. after quickening, any change in pattern or amount- fetal jeopardy/ death. -UCs : pressure; cramping b4 37wks- preterm labor -visual disturbances: blurring double Vision, or spots - hypertensive conditions, preclampsia -swelling of face/finger and over sacrum -hypertensive condition, precl. - headaches: severe, frequent or continuous- -muscular irritability or convulsions -

-epigastria or abd. Pain -glycosuria, positive glucose tolerance test reaction

- and abruptio placentae - gestational diabetes.

11. Discuss recommended weight gain ranges and patterns. Clearly delineate the importance of maternal nutrition, including specific nutrients of especial concern in pregnancy. Teach the client dietary sources of key nutrients-particularly folic acid, iron, calcium, protein, and omega-3 fatty acids and evaluate the clients intake given a dietary recall. -For women with single fetuses current recommendation are that women is with normal BMI should gain 11.5-16 kg during pregnancy. -underweight women should gain 12.5-18 kg -Overweight women should gain 7-11.5 kg -obese women should gain at least 7 kg -adolescents are encouraged to strive for weight gains at the upper end of the recommended range for their BMI due to growing fetus and the mother herself is growing. -Twins gestation total weight gain at term should be 21 to 28 kg for underweight before conception -17-24.5 kg for normal-weight women -16.4- 20.4 kg for overweight women -12-17.7 kg for obese women. Weight gain should take place throughout pregnancy. During the 1st trimester of singleton pregnancy, the average total gain is 1-2.5 kg: thereafter weight gain increases to 0.4 kg per week. Overweight women 2nd and 3rd trimester- 0.3 kg and 0.5 kg Twins gestation- 0.3- 0.8kg per week Protein- essential for rapid growth of fetus, enlargement of the uterus and its supporting structures, increased amounts of plasma protein to maintain colloidal osmotic pressure and formation of amniotic fluid Milk, cheese, eggs, and meat are complete protein foods. Legumes, whole grains and nuts also are valuable sources of protein. 3 servings of milk yogurt or cheese and 2 servings of meat poultry or fish would supply recommended protein for the pregnant women. Fluid- essential during the exchange of nutrients and waste products across cell membrane, water is the main substances of cells, blood, lymph, amniotic fluid and other vital body fluids. It also aids in maintaining body

temperature. A good fluid intake promotes regular bowel functions, which is sometimes a problem in pregnancy. Recommended daily intake is about 812 glasses of fluid. Dehydration can cause the risk of cramping, contractions and preterm labor Caffeine- moderate amount is ok ( more than 300mg-3cups may increase risk of miscarriage and giving to infant with IUGR. Iron - allows to transfer of adequate iron to the fetus and to permit expansion of the maternal RBC mass. - deficiency can result in pre-term labor - recommendation is to receive a supplement of 30mg of ferrous iron daily. - increase intake in vit.C- it helps increase in absorption of iron supplement, therefore include citrus fruits, tomatoes, melons and strawberries and heme iron( meat) -avoid bran, tea, coffee, milk, spinach, swiss chard, egg yolk decrease iron absorption. Avoid taking them at the same time with the supplement. Iron best absorb on empty stomach (between meals/ beverage other then tea, milk and coffee. -take it at bed time if abdominal discomfort, if missed take it ASAP w/in 13hrs of scheduled dose. DO Not DOUBLE the dose. -causes black or dark green stools. And constipation is common w/ iron supplement. Diet high in fiber with adequate fluid intake is recommended. calcium - no increase in the DRI of calcium during pregnancy and lactation. 1000mg daily for women 19 yrs and older. 1300mg for those younger. Milk , yogurt are rich sources of calcium. Fish, beans and legumes, greens, baked products(cornbread, English muffins, French toast, waffles), fruits(dried figs, orange juice w/ calcium added). calcium supplements also may be recommended. Folic acid- needed b4 preconceptions- helps protect against neural tube defect. It is necessary for normal formation of the spinal cord. Advised to intake 0.4mg daily in fortified foods( ready to eat cereals and enriched grain products or supplement. Rich in folic acid- green leafy vegetables, whole grains and fruits., liver of chicken, turkey, goose, lamb, beef. omega 3 fatty-acid

12. Explain the discomforts of pregnancy based on the related pregnancy changes in anatomy and physiology and discuss the trimester(s) in which they are commonly experienced.

13. Implement nursing interventions and teach the client possible relief measures for each discomfort of pregnancy. First trimester Breast changes-(caused by hypertrophy of mammary glandular tissue and increased visualization, pigmentation)- wear supportive maternity bra with pads to absorb discharge. Wash w/ warm water and keep dry. Urination frequency and urgency - (caused by engorgement &altered bladder functions caused by hormones/bladder capacity reduced by enlarging of uterus and fetal presentation)- empty bladder regularly, perform Kegel Exercise, limit fluid intake before bedtime, wear perinea pad, report pain or burning sensation to the doctor. Fatigue( early pregnancy)- ( caused by unexplained may be due to estrogen, progesterone)- rest as needed. Eat well-balanced diet to prevent anemia. N &V- morning sickness,- (caused by hormonal changes/ hCG) -avoid empty or overloaded stomach. Maintain good posture. Give stomach enough room. Stop smoking, eat dry Carbs. Eat 5-6 small meals per day. Avoid greasy, spicy or gas-forming foods. Ptyalism-(excessive salivation)- (cause by elevated estrogen levels)- use astringent mouth wash, chew gum, eat hard candy as comfort measure second trimester Pigmentation deepens, acne, oily skin -(caused by stimulating hormone)- not preventable Spider nevi (caused by focal networks o dilated arterioles from extra estrogen)-not preventable. Pruritus- (unknown cause)-keep fingernails short and clean. Palpitations ( unknown cause) not preventable. Supine hypotension-( by pressure of gravid uterus on ascending vena cava when woman is supine, reduces utero-placental and renal perfusion.)-side lying position or semi sitting posture with knees slightly flexed. Faintness and rarely -( caused by postural hypotension from hormones)moderate exercise, deep breathing, vigorous leg movement, avoid sudden changes in position and warm crowded areas. Food craving-( unknown cause)- not preventable. Heartburn( cause by progesterone slows GI tract motility and digestion, stomach displaced upward and compressed by enlarging uterus)-limit and avoid gas-producing or fatty foods and large meals, maintain good posture, sip milk for temporary relief Constipation- (caused by GI tract motility slowed because of progesterone,

resulting in increase resorption of water and drying of stool.)- drink 8-10 glasses of per day. Include roughage in diet, exercise and regular schedule for bowl movement. Deep breathing exercise. dont take stool softener, laxatives, mineral oil, other drugs or enemas., Flatulence/bloating(caused by reduced GI motility because of hormones)chew foods slowly and thoroughly: avoid gas-producing foods, fatty foods large meals, exercise and maintain regular bowel movt. Headache- (caused by emotional tension, eye strain)- conscious relaxation Carpal tunnel(caused by compression of median nerve resulting from changes in surrounding tissues, pain, numbness,) not preventable. Elevate affected arm, splinting of affected hand may help. Periodic numbness, tingling- (caused by brachial plexus traction syndrome resulting from dropping shoulders during pregnancy.)- maintain good posture, wear supportive bra Third trimester SOB and dyspnea(caused by expansion of diaphragm limited by enlarging uterus)- good posture, sleep with extra pillows, avoid overloading stomach, stop smoking. Insomnia(sleeplessness)-(caused by fetal movt. Muscle cramping, urinary frequency and SOB)- reassurance, conscious relaxation, back massage or effleurage, support of body parts w/ pillows, warm shower or milk b4 retiring. Mood swings- (caused by hormonal and metabolic adaptation, feelings about impending labor, birth, and parenthood.)-reassurance and support from significant other and family members. Urinary frequency and urgency( caused by vascular engorgement and altered bladder functions caused by hormones and reduction in capacity due to enlargement of uterus and fetal presentation.)- empty bladder regularly, Kegel exercises, limit fluid intake b4 bedtime, wear perinea pad. Perinea discomforts and pressure( caused by pressure from enlarging uterus, especially when standing or walking, multi-fetal gestation)-rest conscious relaxation, and for labor.)-rest, change in position, practice breathing technique when contractions are bothersome Leg cramping-(caused by compression of nerves supplying lower extremities due to enlarging of uterus)- check for Homans sign, if negative use massage and heat over affected muscle Ankle edema( caused by edema aggravated by prolonged standing, sitting, poor posture and lack of exercise, constructive clothing or hot weather)-

ample(plenty) fluids intake for natural diuretic effect. Put on support stockings before arising, rest periodically with legs and hips elevated. 14. Teach the client self-care measures for pregnancy and provide anticipatory guidrance including information related to physical activity, Physical activity- physical activity promotes a feeling of well-being in the pregnant woman. Improves circulation, promotes relaxation and rest and counteracts boredoms. Avoid activities that require holding your breath. Seek help in determining an excise routine that is well within your limit of tolerance. Avoid risky activities such as surfing, mountain climbing and sky diving -Exercise regularly. about 30 minutes of moderate physical exercise is recommended. Decrease exercise level as pregnancy progress. Take your pulse and if more than 140 beats/ min slow down until it returns to a maximum of 90 beats/ minute, - avoid hot tubs and saunas. After the fourth of gestation, dont perform exercise flat on ur back. -need a cool down period of mild exercise involving leg execise. -rest for 10 min after exercise lying on your side. As the uterus grows, it puts pressure on a major vein in your abdomen which carries blood to your heart. Rise gradually from the floor to prevent dizziness or fainting. -drink 2-3 glasses of water after you exercise to replace the body fluids lost through perspiration. -wear supportive shoes and stop exercising immediately if experiencing SOB, dizziness, numbness, tingling and decrease fetal activity. Employment- excessive fatigue is usually the deciding factor in the employment. Use good body mechanics, use safety seat belts, shoulder harness etctake rest period. - with sedentary jobs, walk around at intervals to counter the usual sluggish circulation in the legs. Neither sit or stand in one position for a long period of time and avoid crossing their legs at the knee. Use of footstool can prevent pressure on veins, relieve strain on varicosities, minimize edema of feet, and prevent backache. Travel- women with high risk pregnancy are advised to avoid long-distance travel after fetal viability has been reached. Avoid traveling to places where there is poor medical facilities, untreated water, or malaria. Vaccinations for foreign travel may be contraindicated. -for long distance travel, should schedule periods of activity and rest. Practice deep breathing while sitting and foot circulation. Traveling in car should wear automobile restrains and stop and walk every hour.

-The lap belt should be worn low across the pelvic bones and as snug as is comfortable. Harness should be worn above the gravid uterus and below the neck to prevent chafing. Sit up right. Take 15min walk around aircraft during each hour of travel to minimize to prevent DVT. 16. Explain normal uterine involution; describe normal lochia stages. -return of the uterus to a non- pregnant state after birth is known as involution . This begins immediately after expulsion of placenta w/ contraction of the uterine smooth muscle. Involution progress rapidly during the next few days. By the 6th postpartum day, fundus is normally located. Uterus should not be palpable abdominally after 2 weeks. NORMAL LOCHIA STAGES - post child birth uterine discharge is initially bright red/ may contain small clots. First 2hrs amount should be of heavy period, after that should steadily decrease. Lochia rubra-bright red- mainly of blood and decidual and trophoblastic debris. Lochia serosa- pink or brown after 3-4 days consist of old blood, serum, leukocytes and tissue debris lasts 22-27 days Lochia albayellow to white discharge leukocytes, decidua, epithelial cells, mucus, bacteria and serum. lasts 10-14days 17. Discuss culture and family in relation to the perinated period and develop cultural competence in nursing care. Many cultures conflict w/ the beliefs and practice of medical care. Other factors such as lack of money, transport and language barrier, prevents women to participate in the prenatal care system. -exposing body parts is considered a major violation of their modesty. Too often health care providers assume women loose this modesty during pregnancy and labor but actually most women value and appreciate efforts to maintain their modesty. -when exploring cultural beliefs and practices related to childbearing, the nurse can support and nurture those beliefs that promote physical or emotional adaptation. If potential harmful beliefs or activities are identified, the nurse should carefully provide education and propose modification. 18. Assess and teach effective breastfeeding management including recognizing early feeding cues, correct latch, and signs of adequate milk transfer/intake

Physical assessment of the newborn reveals signs that the baby is physiologically ready to begin feeding. -vital signs w/in normal limits, unlabored respirations, nares patent, no cyanosis, active BS, no abdominal distentions. Newborns cry vigorously when they feel hunger. Some infants will withdraw into sleep due to discomforts associated hunger. Instead of waiting to feed until the infant is crying in a distraught manner or withdrawing into sleep, it is better to begin a feeding when the baby exhibits some of these cues, even when sleeping. (feeding cues) -hand to mouth or hand to hand movements - sucking motions -rooting -mouthing The mother tickles the babys lower lip with the tip of her nipples, stimulating the mouth to open Correct latch on- when the mouth is open and the tongue is down, the mother quickly pulls the baby onto the nipple. Bring the baby to the nipple not the breast to the baby. The babys mouth should cover the nipple and an areolar radius 2-3 cm around the nipple. When a baby is latched on properly, the tip of the nose, cheeks, and chin should all be touching the breast. - the mother reports a firm tugging sensation on her nipples but no pinching or pain. -The baby sucks w/ cheeks rounded, not dimpled. -The babys jaw glides smoothly w/ sucking -Swallowing is audible. If the mother feels pinching or pain after each initial sucks, latch on should be evaluated. Not good is when clicking, or smacking is audible. Adequate transfer of milk- behavior after and between feedings: contented, sleepy. Elimination: w/in 24 hrs after birth, at least one diaper and one stool. The baby is alert when awake and appears well hydrated, with normal skin turgor and moist mucus membrane. The fontanels are soft and flat and the baby demonstrates a strong and coordinated suck. Periods of wakefulness and hunger alternate with periods of contentment or sleepin. Weight loss is less then 7% by 3 after birth and the infant gains 20 to 28g/day after milk is in -in the first 3 days of life, a newborn should have at least 1 wet diaper and 1 stool for each day. Day 4- the baby should have 6 -8 wet diapers Q24 hrs. may stool w/ every feeding but should minimally have 3 bowel movt. Q24 hrs. stools transition from meconium to milk stools, becoming lighter in

color be day 3and by 5-appearing mustard-yellow in color. 19. Teach safe preparation and use of formula and provide supportive care for the non-breastfeeding mother experiencing breast discomfort with lacto genesis. -Wearing a well-fitted support bra or breast binder continuously for at least the first 72hour after giving birth is important (when not breast feeding) -Women should avoid breast stimulation, running warm water over the breast, newborn suckling or pumping of the breast. -Ice packs to the breast are helpful in decrease the discomfort associated w/ engorgement (swelling of the breast tissue caused by increase of blood and lymph supply to the breasts as the body produces milk. -place fresh cabbage leaves inside bra- tx swelling. Preparing formula -Wash your hands and clean the bottle, nipple and can opener carefully before preparing formula. -Read and follow instructions and mix it exactly according to directions. -Use tap water unless indicated by doctor or nurse. -Opened cans of ready to feed or concentrated formulas should be covered and refrigerated. Any unused portions must be discarded after 48 hours. Record on the can the date and time it was opened. - never use microwave to warm up the refrigerated milk. Place it in hot water pan - should be fed q 3-4 hours and never go longer then 4 hours. If any formula remains in the bottle as the feeding ends, that milk must be thrown away. Spitting- need to decrease the amount of feeding or feed smaller amounts more frequently. Burping the infant several time during a feeding. - for feeding hold the baby close in a semi-reclining position. -place the nipple in the babys mouth on the tongue. It should touch the roof of the mouth to stimulate the babys sucking reflex. Hold the bottle like a pencil. -after the first 2-3 days, the stools of a formula fed infant are yellow and soft, but formed. The baby to have a stool w/ each feeding in the first 2 wks. Although this may decrease to one or 2 stools each day.