WHAT YOU SHOULD KNOW BEFORE THE PNLE

DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

A. Pregnancy  SHOULD REFRAIN FROM

 Ovum: From ovulation to fertilization SEXUAL INTERCOURSE
 Zygote: From fertilization to implantation AND PHYSICAL ACTIVITY
 Embryo: From implantation to 5-8 weeks. FOR 48 hours.
 Fetus:From 5-8 weeks until term  A small amount of
spotting is normal for the
Length of Pregnancy 1st 24-48 hours.
267-280 days
38-42 weeks (ave.40 weeks) ULTRASOUND  Done 18-40 weeks for
9 calendar months fetal abnormalities.
10 lunar months Use of sound and  Best Test for ECTOPIC
3 trimester returning echo PREGNANCY
First Trimester: Period of Organogenesis patterns to identify  Full Bladder
Second Trimester: Most comfortable for mother intrabody structures.  Use to locate the precise
with continued fetal growth. location of the fetus and
Third Trimester: Period of rapid fetal growth its membrane during CVS
bec. of rapid deposition of fats and amniocentesis
iron and calcium AMNIOCENTESIS  Possible after the 14th
week.
B. Signs of Pregnancy Aspiration of amniotic  The client should be
fluid for examination. supine during the
 Presumptive Signs procedure
Amenorrhea – absence of menses  Afterward, she should be
Nausea and Vomiting placed on her left side.
Increased breast sensitivity and breast changes  The patient MUST
Increased pigmentation EMPTY THE BLADDER.
Constipation  Vital signs are assessed
Frequent urination every 15 minutes.
Quickening  CALL THE PHYSICIAN
Abdominal enlargement FOR THE FF: Chills, fever,
leakage of fluid, decrease
 Probable Signs fetal movement or
uterine contractions.
Uterine enlargement
Hegar’s Sign
X-RAY  Done only 2 weeks
Goodell’s Sign
before EDC
Chadwick’s Sign
Ballottement
ALPHA-FETOPROTEIN  Test done between 16
Braxton Hick’s contraction SCREENING and 18 weeks
Positive Pregnancy Test gestation.
Maternal serum  Normal Value: 10
 Positive Signs screens for open mg/dl
Fetal Heart Tone neural tube defects.  LOW: Chromosomal
X-ray or Ultrasound of fetus defects
Palpable fetal movements  HIGH: Neural tube
defects.
C. Maternal and Fetal Diagnostic Test
LECITHIN -  Done through
CHORIONIC VILLI  Performed between the SPHINGOMYELIN – AMNIOCENTESIS
SAMPLING 8th – 11th weeks of (L/S RATIO)  Perform at 35-36 weeks
gestation.  Position: Supine.
Removal of a small  Laboratory results are Uses amniotic fluid to  Place folded towel on the
piece of Chorionic villi obtained in 1 - 7 days ascertain fetal lung right buttocks.
maturity  Needle insertion in a 20-
Disadvantages: 22 gauge spinal needle,
Risk of Abortion withdrawing amniotic
Infection fluid.
Embryo-fetal/placental  NORMAL L/S RATIO
damage (lecithin/sphingomyelin)
Spontaneous abortion : 2:1 = normal fetal lung
Premature rupture of the maturity ratio
membranes

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

LEOPOLDS  Palpate with warm hands. Constipation Due to Increased fluids and
MANEUVER  Use palms, not fingertips. displacement roughage in the diet.
 Woman should lie in of the stomach Regular elimination
supine position with knees and intestines; time.
flexed slightly. iron Increase exercise
 Done with empty bladder. supplements Avoid enemas, harsh
1st: Presenting Part laxatives and mineral
2nd: Fetal Back oil.
3rd: Engagement Hemorrhoids Pressure of Warm sitz bathing
4th: Descent growing fetus, High fiber diet and
Increase increase fluid.
venous Sit on soft pillow
TeTox Routine Immunization of Pregnant Women pressure
Urinary Increase blood Sleep on the side at
Vaccine Minimum Duration of Frequency supply to the night.
Interval Protection kidney/ Limit fluid intake
TeTox 1 As early as Pressure of during evening
possible enlarged Bladder training
during uterus in the
pregnancy 3rd Tri
TeTox 2 4 weeks after infant will be Backache From Back exercise (pelvic
TeTox 1 protected by exaggerated rock)
Minimum neonatal tetanus lumbo-sacral Wear low-heeled shoes.
required 3 years protection curving during Avoid heavy lifting
TeTox for for the mother pregnancy.
pregnant Leg Cramps Increase Frequent rest with feet
mother pressure of elevated
TeTox 3 6 months infant will be gravid fetus, Regular exercise like
after TeTox 2 protected by low calcium walking
neonatal tetanus Increase milk intake
5 years protection Ankle Edema From venous Elevate legs at least
for the mother stasis twice a day.
TeTox 4 1 year after infant will be Sleep on left side
TeTox 3 protected by Fatigue Due to Get regular exercise
neonatal tetanus hormonal Sleep as much as
10 years changes needed.
protection for the
Avoid stimulants.
mother
Breast Increase Wear well fitted bra
TeTox 5 1 year after all infant born to
Tenderness estrogen and Warm compress
TeTox 4 that mother will be
progesterone
protected
level
lifetime protection
for the mother
E. Formula Used In Providing Estimates In Pregnancy
D. Discomfort of Pregnancy To estimate the EDC
Changes Reason Health Teachings Given the Use Formula
Nausea and Increased HCG Dry crackers 30 min. Last Menstrual Nagele’s Rule First day of LMP –
Vomiting before arising Period (LMP) 3 months + 7 days
Small, frequent, low fat Date of Primi:
meals Quickening Q + 4 months + 20
Avoid anti-emetics. days
Heartburn Increased Pats of butter before
progesterone meals Multi:
which decrease Avoid fried, fatty foods Q + 5 months + 4
gastric motility Sips of milk at frequent days
causing intervals.
esophageal Small, frequent meals
reflux. taken slowly.
Bends at the knees, not
at the waist
POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

Fundus Height at Various Week INTERPRETATION:

Early Deceleration: Head Compression
Late Deceleration: Utero-placental Insufficiency
Variable Deceleration: Cord Compression

H. Signs of Labor
1. Lightening – setting of fetal head into pelvic brim
 occurs approximately 10-14 days before labor .
 mother may experience: shooting leg pains from
the increased pressure on the sciatic nerve,
increased amounts of vaginal discharge and
urinary frequency from pressure on the bladder
2. Increased in Level of Activity
3. Braxton Hicks Contractions
4. Ripening of the cervix
5. Weight Loss
6. Rupture BOW
7. Effacement and Dilation

I. Length of Labor
F. Pre-Natal Visit
Stages of Labor Primigravida Multigravida
Schedule of first visit is as soon as the woman missed her First Stage 12 and ½ hour 7hours and 20
menstrual period and pregnancy is suspected minutes
Second Stage 80 minutes 30 minutes
First 32 weeks : once a month
32-36 weeks : twice a month Third Stage 10 minute 10 minutes
36-40 weeks : every week TOTAL 14 hours 8 hours

G. Electronic Monitoring J. Nursing Care During Labor

Non-Stress Test 1st Stage Latent

 Accelerations in heart rate accompany normal fetal  Contractions are mild and short
movement. Onset of true labor lasting 20-40 seconds
 Observation of fetal heart rate related to fetal pain until  Cervix dilates from 0-3cm
movement. complete cervical Monitor frequency, intensity, and
FHT: Doppler: 8 weeks dilation and patterns of uterine contractions
Fetoscope: 16 weeks / 4 months effacement Monitor fetal status during labor by
Stethoscope: 20 weeks / 5months monitoring fetal heart rate
 Teach mother to count 2-3 times daily, 30-60 minutes Assess bloody show (pink or blood
each time, should feel 5-6 movements per counting streaked mucus), perineal bulging,
time membrane status
PREPARATION:
Monitor vital signs
 Patient should eat snacks.
Assess client’s ability to cope with
 Position: Semi-Fowlers or left lateral positions
contractions
RESULTS:
1. Reactive (Normal): indicates a fetal fetus Provide emotional support
 Greater than 15 beats per minute- occur with
fetal movement in a 10 or 20 minute period. Active
2. Non-Reactive (Abnormal):  Dilatation increases from 4 – 7 cm
 Contraction lasts 40-60 sec and occur
 No fetal movement occurs
every 3-5 minutes
 The doctor will order an Oxytocin Test
AFTER the patient has non-reactive test. Finds assessment techniques
between contractions
Contraction Stress Test (CST) Assists with frequent position
 Response of the fetus to induced uterine contractions. change
PREPARATION: Applies counter pressure to
 Woman in semi-Fowler’s or side-lying position. sacrococcygeal area
 Monitor for post-test labor onset. Encourages and praises
 Indication: 28 weeks pregnancy high risk mother Keeps woman aware of progress
 Contraindicated: Pre Term Labor Check bladder and encourages
voiding

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

Transitional K. Micronutrient Supplementation

 Contractions reached their peak of
intensity occurring every 2-3 minutes Vitamin A Supplementation
with duration of 60-90sec
 Maximum dilatation 8-10cm Target Prep. Dose Duration
 Complete cervical effacement Pregnant 100,000 1 cap Start from the 4th month
Woman experiences intense Women IU 2x a of pregnancy until
discomfort accompanied by nausea week delivery
and vomiting Post 200,000 1 cap One dose only within 4
Woman may also experience a Partum IU weeks after delivery
feeling of loss of control, anxiety, Women
panic or irritability
Iron Supplementation
2nd Stage Prep client for delivery
Immediate assessment of the Target Prep. Dose / Duration Remarks
From complete newborn Pregnant Coated 1 tab/day for 6
dilation and 6 Cardinal Movements of the Women Tab. months or 180 days
effacement to Mechanism of labor contains during pregnancy
delivery of the 1. Descent 60 mg period A dose of
fetus 2. Flexion elemental OR 800 mcg
3. Internal Rotation iron with 2 tab/day if prenatal folic acid is
4. Extension 400 mg consultation are still safe to
5. External Rotation folic acid done during the pregnant
6. Expulsion 2nd/3rd trimester woman
3rd Stage Assess umbilical cord for 3 vessels Lactating Coated 1 tab / day for 3
(2 arteries, 1 vein) Women Tab. months or 90 days
From delivery of Assess placenta for intactness contains
the fetus to The fundus should be midline at or 60 mg
delivery of the 2 cm. below the umbilicus elemental
placenta Don’t hurry the expulsion of the iron with
placenta, just watch for the signs of 400 mg
placental separation: folic acid
Lengthening of the cord
Sudden gush of blood
Change of shape of the uterus L. Pregnancy Complications
Palpate the uterus to determine
degree of contraction. If relaxed, ABORTION
massage gently and apply ice cap  Threatened, the continuation of the pregnancy is in
Inspect for lacerations doubt
The fundus should descend  Inevitable, loss that can be prevented
approximately 1-2 cm every 24  Complete, products of conception are totally expelled
hours  Incomplete, some fragments are retained inside the
4th Stage Promote parent-infant bonding uterine cavity
Assess maternal vital signs, fundal  Missed, retention of the products of conception after
The period of height, lochia and bladder fetal death
immediate distention  Habitual, 3 spontaneous abortions occurring
recovery and successively
observation after Degrees of Perineal Lacerations:
delivery of the ECTOPIC PREGNANCY
placenta 1. First Degree – skin and superficial to  A pregnancy that occurs in another than uterine
muscle site, with implantation usually occurring in fallopian
2. Second Degree – muscles of the tubes
perineum  Knife-like abdominal pain
3. Third Degree – continues to anal  Profound shock if rupture occurs
sphincter Symptoms of Shock:
4. Fourth Degree – involves the anterior decreased BP
anal wall Increased RR,
Fast but thready pulse
 Surgery: Salpingostomy

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 2: MATERNAL AND CHILD HEALTH NURSING
INCOMPETENT CERVIX
 Painless premature dilatation of the cervix (usually in
the 16th to 20th week)
 #1 Sign: Rupture of membranes and discharge of
amniotic fluid
 Best Position: Side lying position
 Pre-op: Encourage patient to maintain bed rest
 Post-op: Check for excessive vaginal discharge and
severe pain.
 Bed rest in trendelenburg position
 Administer tocolytic medications as ordered
Eg; Ritodrine Hydrochloride (Yutopar)
 Surgery: Cervical Cerclage
 Shirodkar-Barter Technique ( internal
os) permanent suture: subsequent
delivery by C/S.
 Mc Donald Procedure ( external os)-
suture removed at term with vaginal
delivery
CARDIAC DISEASE
 Class I: no limitation of activities. No symptoms of
cardiac insufficiency.
 Class II: slight limitation of activity, Asymptomatic
at rest. Ordinary activities causes fatigue,
palpitations and dyspnea
 Class II: marked limitation of activities, comfortable
at rest, less than ordinary activities causes
discomforts
 Class IV: unable to perform any physical activity
without discomfort. May have the symptoms during
rest.
GESTATIONAL DIABETES
 Diabetes during pregnancy.
 3-P’s: Polyuria, Polydipsia and Polyphagia
 Because insulin does not pass into the breast
milk, breastfeeding is not contraindicated for the
mother with diabetes
 Maternal Complications: PIH, Placental disorders,
stillbirth, macrosomia, neural tube defects.
 Screen clients between the 24th and 28th weeks of
pregnancy
 If a pregnant diabetic is in labor, her blood glucose
should be monitored hourly.
 Treatment: Insulin therapy (don’t use Oral
hypoglycemics, they are Teratogenic)
PREGNANCY INDUCED HYPERTENTION (PIH)
 Blood pressure over 140/90, or increase of 30 mm
systolic, 15 mm diastolic over pre-pregnancy level
 Pre Eclampsia: HPN, Protenuria , Edema
(face&hand)
 Eclampsia: HPN, Protenuria, Edema plus Fever and
Epigastric pain.
 During pregnancy, blurred vision may be a danger
sign of preeclampsia or eclampsia.
 Monitor VS, I&O and breath sound
POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 ECLAMPSIA: to prevent aspiration, turn the
woman on her side to allow secretions to drain
from her mouth.
 SEVERE PRECLAMPSIA: Lateral recumbent
position
 DOC: Magnesium Sulfate
 Magnesium Sulfate Toxicity:
Decrease urine output
Decrease RR
Absence of reflexes
 Antidote: CALCIUM GLUCONATE
PLACENTA PREVIA
 Improperly implanted placenta in the lower uterine
segment near or over the internal cervical os
 Total: the internal os is entirely covered by the
placenta when cervix is fully dilated
 Marginal: only an edge of the placenta extends to
the internal os
 Low-lying placenta: implanted in the lower uterine
segment but does not reach the os
 Painless Bleeding
 #1 Assessment - Monitor maternal vital signs,
FHR, and fetal activity
 Best Position: Left Lateral
ABRUPTIO PLACENTA
 Premature separation of the placenta from the
uterine wall after the 20th week of gestation and
before the fetus is delivered.
 Abruptio placentae is associated with conditions
characterized by poor uteroplacental circulation,
such as hypertension, smoking and alcohol or cocaine
abuse.
 Painful vaginal bleeding
 Board-like rigidity of abdomen
 The goal of management in abruption placentae is to
control the hemorrhage and deliver the fetus as soon
as possible
M. Post Partum
LOCHIAL CHANGES
 Lochia Rubra
• Dark red discharge occurring in the first 2-3 days.
• Characteristic human odor.
 Lochia Serosa
• Pinkish to brownish discharge occurring 3-10 days
after delivery.
• Has a strong odor.
 Lochia Alba
• Almost colorless to creamy yellowish discharge
occurring from 10 days to 3 weeks after delivery.
• Has no odor.
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

UTERINE INVOLUTION intake

 Process of involution takes 4-6 weeks to complete. DIGESTIVE IMMATURE CARDIAC SPHINCTER
 Weight decreases from 2 lbs to 2 oz. SYSTEM – may allow reflux of food, burped,
 Fundus steadily descends into true pelvis; Fundal height REGURGITATE-placed NB right
decreases about 1 fingerbreadth (1 cm)/day; by 10-14 side after feeding
days postpartum, cannot be palpated abdominally. FIRST STOOL is MECONIUM
- Black, tarry residue from
lower intestine
- Usually passed within 12-24
hours after birth
TRANSITIONAL STOOLS thin,
brownish green in color
After 3 days MILK STOOLS:
a. MILK STOOLS for BF infant –
loose and golden yellow
b. MILK STOOLS for
FORMULATED FED- formed
and pale yellow
HEPATIC Pathologic Jaundice, yellowish
discoloration immediately after
birth
Physiologic Jaundice, yellowish
discoloration 2-3 days after birth
(normal)
NOTE: Deviation of the fundus to the right or left and location TEMPERATURE Axillary temperature: 96.8 to 99F
of the fundus above the umbilical are signs that the bladder is Newborn can’t shiver as an adult
distended does to release heat
Cold stress increases o2
N. Care of the Newborn consumption – may lead to
metabolic acidosis and respiratory
 Suction the mouth first before the nose distress
 Delay initial bath until temp. has stabilized for at IMMUNOLOGIC NB develops own antibodies
least 6 hours. during 1st 3 months but at risk for
 APGAR scoring is taken twice: initially @ 1 minute, infection during the first 6 weeks
and then @ 5 minutes after birth
 Give prophylactic eye treatment (credes ointment)
against gonorrheal conjunctivitis or ophthalmia P. Freud’s Theory
neonatorum within the first hour after delivery.
 Prevent hemorrhage , give 0.5mg (preterm) to 1 Freud’s Psychoanalytic Theory
mg (full term) Vit. K or Aquamephyton is injected Psychosexual Development
IM in the NB’s vastus lateralis (lateral anterior Infants Oral Stage
thigh)muscle (birth to 1  Child explores the world by using
 The cord is clamped and cut approximately within year) mouth, especially the tongue
30 seconds after birth when cord pulsation stop  Baby finds pleasure in the mouth
 The cord stump usually dries and fall within 7 to Toddler Anal Stage
10 days (1-3 y/o)  Child learns to control urination and
defecation (18 months)
O. Newborn Assessment  Toilet training
Preschooler Phallic Stage
CIRCULATORY DUCTUS ARTERIOSUS constrict (3-6y/o)  The genitals are the pleasure of the
STATUS with establishment of respiratory child
function, remains open cause PDA  Oedipus and Electra Complex
(patent ductus arteriosus)  Masturbation is common during this
FORAMEN OVALE closes phase and may also show
functionally as respirations exhibitionism
established, remains open cause School-Age Latent Stage / Latency Period
ASD (atrial septal defect) (6-12 y/o)  Child’s personality development
RESPIRATORY RR = 30-80 breaths /minutes with appears to be nonactive or dormant
STATUS short periods of apnea (< 15 Adolescent Genital Stage
seconds) (13-20 y/o)  Adolescent develops sexual maturity
RENAL SYSTEM Later pattern is 6-10 voidings/ and learns to establish satisfactory
day – indicative of sufficient fluid relationships w/ the opposite sex

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 2: MATERNAL AND CHILD HEALTH NURSING

Q. Erikson’s Theory R Physical Growth and Development

Erikson’s Theory of
Psychosocial Development Mo. Gross Fine Motor
Infants Trust vs. Mistrust Yr. Motor Development Development
(birth to 1  Fear: strangers, anxiety, loud noises,  Largely reflex  The eyes is fixated on
year) falls, sudden movements in the 0-1 the person
environment  Keeps hands fisted
 Play: Solitary  Holds head up  Development of
 Learning confidence or learning to when prone social smile
love, 2  Responds to familiar
Toddler Autonmy vs. Shame voice
(1-3 y/o)  Psychosocial Theme: “hold on or let  Holds head & chest  The baby knows how
go” up when prone to cry
 Play: Parallel 3  Laughs aloud
 Child learns to be independent and  Babbles and “coos”
make decisions for self  Grasp  Can raise head and
 Favorite word: “I”, “no”  Stepping chest
Preschooler Initiative vs. Guilt  Tonic neck  Reach out to object
(3-6y/o)  Ability to try new things 4  Reflexes are fading
 Bogus playmates/imaginary  Turns front to back  Roll over
 Fears: dark, being left alone, large 5  Has head lag when  Hold blocks at each
animals, ghosts, body mutilation, pulled upright hand
pain & objects
School-Age Industry vs. Inferiority  Turns both ways  Doubles birth weight
(6-12 y/o)  Makes things w/ others  Moro reflex fading  Eruption of 1st tooth
 Strives to achieve success  Sits w/ minimal
 Child learns how to do things well 6 support
Adolescent Identity vs. Role Confusion  Uses palmar grasp
(13-20 y/o)  Determines own sense of self  Reaches out in  “dada”, “mama”
 Development of who, what & where anticipation of  Sleeps on prone
they are going being picked up position
 Adjusting to a new body and seeking 7  Sits unsteadily  Uses fingers to hold
emancipation from parents, choosing objects
a vocation & determining a value  Transfers objects
system hand to hand
Young Intimacy vs. Isolation
Adult  Person makes commitments to one  Sits securely w/o  Sits alone steadily for
another support an indefinite period
 Isolation and self absorption if 8  Recognizes strangers
unsuccessful  Peek-a-boo (to test
 Independent from parents, possible memory)
marriage / partnership
 Major goals to accomplish in career  Creeps or crawls  Can hold own bottle
and family  Starts to crawl
Middle Generativity vs. Stagnation 9  Understands simple
Adult  Physical Changes: graying hair, gestures
wrinkling skin, pain & muscle aches,
menopausal period  Pulls self to  From crawling to
 Mature adult is concerned w/ standing standing
establishing & guiding the new 10  Responds when
generation or else feels personal called by his/her
impoverishment name
 Become “Pillars of the Community”
 From crawling to  Walks with
Older Adult Integrity vs. Despair
11 standing assistance
 Achieves sense of acceptance of own
life
 Stands alone  Triples birth weight
 Adapts to triumphs & disappointment
12  Some infants take  Can say 2 syllable
w/ a certain ego integrity
1st step words
 Can walk w/ help

POSSIBLE TOPICS ON MATERNAL AND CHILD HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming Dec 2012 PNLE