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the postpartum woman are all covered. Treatment and nursing management are presented for each medical condition. This
organization allows the student to build on a solid foundation of normal material when studying the at-risk content.

Unit 8: The Newborn at Risk

U nit 8 continues to center on at-risk content. Issues of the newborn with birthweight variations, gestational age variations,
congenital conditions, and acquired disorders are explored. Treatment and nursing management are presented for each medical
condition. This organization helps cement the student’s understanding of the material.

Unit 9: Health Promotion of the Growing Child and Family

U nit 9 provides information related to growth and development expectations of the well child from newborn through adolescence.
Although not exhaustive in nature, this unit provides a broad knowledge base related to normal growth and development that the
nurse can draw on in any situation. Common concerns related to growth and development and client/family education are included
in each age-specific chapter.

Unit 10: Children and Their Families

U nit 10 covers broad concepts that provide the foundation for providing nursing care for children. Rather than reiterating all aspects
of nursing care, the unit focuses on specific details needed to provide nursing care for children in general. The content remains
focused upon differences in caring for children compared with adults. Topics covered in this unit include atraumatic care,
anticipatory guidance and routine well child care (including immunization and safety), health assessment, nursing care of the child
in diverse settings, including the hospital and at home, concerns common to special needs children, pediatric variations in
medication and intravenous fluid delivery and nutritional support, and pain management in children.

Unit 11: Nursing Care of the Child With a Health Disorder

U nit 11 focuses on children’s responses to health disorders. This unit provides comprehensive coverage of illnesses affecting children
and is presented according to broad topics of disorders organized with a body systems approach. It also includes infectious, genetic,
and mental health disorders as well as pediatric emergencies. Each chapter follows a similar format in order to facilitate
presentation of the information as well as reduce repetition. The chapters begin with a nursing process overview for the particular
broad topic, presenting differences in children and how the nursing process applies. The approach provides a general framework
for addressing disorders within the chapter. Individual disorders are then addressed with attention to specifics related to
pathophysiology, nursing assessment, nursing management, and special considerations. Common pediatric disorders are covered in
greater depth than less common disorders. The format of the chapters allows for the building of a strong knowledge base and
encourages critical thinking. Additionally, the format is nursing process driven and consistent from chapter to chapter, providing a
practical and sensible presentation of the information.

Recurring Features
In order to provide the instructor and student with an exciting and user-friendly text, a number of recurring features have been
developed.

Key Terms
A list of terms that are considered essential to the chapter’s understanding is presented at the beginning of each chapter. Each key
term appears in boldface, with the definition included in the text. Key terms may also be accessed on .

Learning Objectives
Learning Objectives included at the beginning of each chapter guide the student in understanding what is important and why,
leading the student to prioritize information for learning. These valuable learning tools also provide opportunities for self-testing or
instructor evaluation of student knowledge and ability.

Words of Wisdom
Each chapter opens with inspiring Words of Wisdom (WOW), which offer helpful, timely, or interesting thoughts. These WOW
statements set the stage for each chapter and give the student valuable insight into nursing care of women, children, and their
families.

Threaded Case Studies

Real-life scenarios present relevant woman, child, and family information that are intended to perfect the student’s caregiving skills.
Questions about the scenario provide an opportunity for the student to critically evaluate the appropriate course of action.

Evidence-Based Practice
The consistent promotion of evidence-based practice is a key feature of the text. Throughout the chapters, pivotal questions
addressed by current research have been incorporated into Evidence-Based Practice displays, which cite studies relevant to chapter
content.

Healthy People 2020

Throughout the textbook, relevant Healthy People 2020 objectives are outlined in box format. The nursing implications or guidance
provided in the box serve as a roadmap for improving the health of women, mothers, and children.

Atraumatic Care
These highlights, located throughout the pediatric sections of the book, provide tips for providing atraumatic care to children in
particular situations in relation to the topic being discussed.

Thinking About Development

The content featured in these boxes in chapters related to the care of children will encourage student to think critically about special
developmental concerns relating to the topic being discussed.

Teaching Guidelines
An important tool for achieving health promotion and disease prevention is health education. Throughout the textbook, Teaching
Guidelines raise awareness, provide timely and accurate information, and are designed to ensure the student’s preparation for
educating women, children, and their families about various issues.

Consider This!
In every chapter the student is asked to Consider This! These first-person narratives engage the student in real-life scenarios
experienced by their clients. The personal accounts evoke empathy and help the student to perfect caregiving skills. Each box ends
with an opportunity for further contemplation, encouraging the student to think critically about the scenario.

Take Note!
The Take Note! feature draws the student’s attention to points of critical emphasis throughout the chapter. This feature is often used
to stress life-threatening or otherwise vitally important information.

Drug Guides
Drug guide tables summarize information about commonly used medications. The actions, indications, and significant nursing
implications presented assist the student in providing optimum care to women, children, and their families.

Common Laboratory and Diagnostic Tests

The Common Laboratory and Diagnostic Tests tables in many of the chapters provide the student with a general understanding of
how a broad range of disorders is diagnosed. Rather than reading the information repeatedly throughout the narrative, the student is
then able to refer to the table as needed.

Common Medical Treatments

The Common Medical Treatments tables in many of the nursing management chapters provide the student with a broad awareness
of how a common group of disorders is treated either medically or surgically. The tables serve as a reference point for common
medical treatments.

Nursing Care Plans

Nursing Care Plans provide concrete examples of each step of the nursing process and are included in numerous chapters. The
Nursing Care Plans summarize issue- or system-related content, thereby minimizing repetition.

Comparison Charts
These charts compare two or more disorders or other easily confused concepts. They serve to provide an explanation that clarifies
the concepts for the student.

Nursing Procedures
Step-by-step Nursing Procedures are presented in a clear, concise format to facilitate competent performance of relevant procedures
as well as to clarify pediatric variations when appropriate.

Icons

WATCH AND LEARN

A special icon throughout the book directs students to free video clips locate on that highlight growth and development,
communicating with children, and providing nursing care to the child in the hospital.

CONCEPTS IN ACTION ANIMATIONS

These unique animations, also located on bring physiologic and pathophysiologic concepts to life and enhance student
comprehension.

Tables, Boxes, Illustrations, and Photographs

Abundant tables and boxes summarize key content throughout the book. Additionally, beautiful illustrations and photographs help
the student to visualize the content. These features allow the student to quickly and easily access information.

Key Concepts
At the end of each chapter, Key Concepts provide a quick review of essential chapter elements. These bulleted lists help the student
focus on the important aspects of the chapter.

References and helpful Websites

References used in the development of the text are provided at the end of each chapter. These listings enable the student to further
explore topics of interest. Many online resources are provided on as a means for the student to electronically explore
relevant content material. These resources can be shared with women, children, and their families to enhance patient education and
support.

Chapter Worksheets
Chapter worksheets at the end of each chapter assist the student in reviewing essential concepts. Chapter worksheets include:
• Multiple Choice Questions—These review questions are written to test the student’s ability to apply chapter material. Questions
cover maternal-newborn, women’s health, and pediatric content that the student might encounter on the national licensing exam
(NCLEX®).
• Critical Thinking Exercises—These exercises challenge the student to incorporate new knowledge with previously learned
concepts and reach a satisfactory conclusion. They encourage the student to think critically, problem solve, and consider his or her
own perspective on given topics.
• Study Activities—These interactive activities promote student participation in the learning process. This section encourages
increased interaction/learning via clinical, on-line, and community activities.

Teaching–Learning Package
Instructor’s Resources
Tools to assist you with teaching your course are available upon adoption of this text on .
• An E-Book on gives you access to the book’s full text and images online.
• A Test Generator that features hundreds of questions within a powerful tool to help the instructor create quizzes and tests.
• PowerPoint presentations with Guided Lecture Notes provide an easy way for you to integrate the textbook with our students’
class-room experience, either via slide shows or handouts. Multiple choice and true/false questions are integrated into the
presentations to promote class participation and allow you to use i-clicker technology.
• An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in
your course.
• Case Studies with related questions (and suggested answers) give students an opportunity to apply their knowledge to a client
case similar to one they might encounter in practice.
• Pre-Lecture Quizzes (and answers) are quick, knowledge-based assessments that allow you to check students’ reading.
• Discussion Topics (and suggested answers) can be used as conversation starters or in online discussion boards.
• Assignments (and suggested answers) include group, written, clinical, and web assignments.
• Sample Syllabi provide guidance for structuring your pediatric nursing courses and are provided for four different course lengths:
4, 6, 8, and 10 weeks.
• Journal Articles, updated for the new edition, offer access to current research available in Lippincott Williams & Wilkins journals.

Contact your sales representative or check out LWW.com/Nursing for more details and ordering information.

Student Resources
An exciting set of free resources is available to help students review material and become even more familiar with vital concepts.
Students can access all these resources on using the codes printed in the front of their textbooks.
• NCLEX-Style Review Questions for each chapter help students review important concepts and practice for NCLEX. Over 700
questions are included, more than twice as many as last edition!
• Multimedia Resources appeal to a variety of learning styles. Icons in the text direct readers to relevant videos and animations:
• Watch and Learn Videos highlight growth and development, communicating with children, and providing nursing care to
the child in the hospital.
• Concepts in Action Animations bring physiologic and pathophysiologic concepts to life and enhance student
comprehension.
• A Spanish–English Audio Glossary provides helpful terms and phrases for communicating with patients who speak Spanish.
• Journal Articles offer access to current research available in Lippincott Williams & Wilkins journals.

1 Nursing Process Overview contains NANDA-I approved nursing diagnoses. Material related to nursing diagnoses is from Nursing
Diagnoses—Definitions and Classification 2015-2017 © 2014, 2012 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA
International. U sed by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe
and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining
characteristics of the diagnoses listed in this work.
 Contents in Brief

UNIT 1 INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING

CHAPTER 1 Perspectives on Maternal and Child Health Care
CHAPTER 2 Family-Centered Community-Based Care

UNIT 2 Women’s Health Throughout the Life Span

CHAPTER 3 Anatomy and Physiology of the Reproductive System
CHAPTER 4 Common Reproductive Issues
CHAPTER 5 Sexually Transmitted Infections
CHAPTER 6 Disorders of the Breasts
CHAPTER 7 Benign Disorders of the Female Reproductive Tract
CHAPTER 8 Cancers of the Female Reproductive Tract
CHAPTER 9 Violence and Abuse

UNIT 3 Pregnancy
CHAPTER 10 Fetal Development and Genetics
CHAPTER 11 Maternal Adaptation During Pregnancy
CHAPTER 12 Nursing Management During Pregnancy

UNIT 4 Labor and Birth

CHAPTER 13 Labor and Birth Process
CHAPTER 14 Nursing Management During Labor and Birth

UNIT 5 Postpartum Period

CHAPTER 15 Postpartum Adaptations
CHAPTER 16 Nursing Management During the Postpartum Period

UNIT 6 The Newborn

CHAPTER 17 Newborn Transitioning
CHAPTER 18 Nursing Management of the Newborn

UNIT 7 Childbearing at Risk

CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications
CHAPTER 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations
CHAPTER 21 Nursing Management of Labor and Birth at Risk
CHAPTER 22 Nursing Management of the Postpartum Woman at Risk

UNIT 8 The Newborn at Risk

CHAPTER 23 Nursing Care of the Newborn with Special Needs
CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions

UNIT 9 Health Promotion of the Growing Child and Family

CHAPTER 25 Growth and Development of the Newborn and Infant
CHAPTER 26 Growth and Development of the Toddler
CHAPTER 27 Growth and Development of the Preschooler
CHAPTER 28 Growth and Development of the School-Age Child
CHAPTER 29 Growth and Development of the Adolescent

UNIT 10 Foundations of Pediatric Nursing

CHAPTER 30 Atraumatic Care of Children and Families
CHAPTER 31 Health Supervision
CHAPTER 32 Health Assessment of Children
CHAPTER 33 Caring for Children in Diverse Settings
CHAPTER 34 Caring for the Special Needs Child
CHAPTER 35 Key Pediatric Nursing Interventions
CHAPTER 36 Pain Management in Children

UNIT 11 Nursing Care of the Child With a Health Disorder

CHAPTER 37 Nursing Care of the Child With an Infectious or Communicable Disorder
CHAPTER 38 Nursing Care of the Child With an Alteration in Intracranial Regulation/
Neurologic Disorder
CHAPTER 39 Nursing Care of the Child With an Alteration in Sensory Perception/
Disorder of the Eyes or Ears
CHAPTER 40 Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder
 CHAPTER 41 Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder
CHAPTER 42 Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder
CHAPTER 43 Nursing Care of the Child With an Alteration in U rinary Elimination/Genitourinary Disorder
CHAPTER 44 Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder
CHAPTER 45 Nursing Care of the Child With an Alteration in Tissue Integrity/
Integumentary Disorder
CHAPTER 46 Nursing Care of the Child With an Alteration in Cellular Regulation/
Hematologic or Neoplastic Disorder
CHAPTER 47 Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder
CHAPTER 48 Nursing Care of the Child With an Alteration in Metabolism/
Endocrine Disorder
CHAPTER 49 Nursing Care of the Child With an Alteration in Genetics
CHAPTER 50 Nursing Care of the Child With an Alteration in Behavior, Cognition, or Development
CHAPTER 51 Nursing Care During a Pediatric Emergency

Appendix A Standard Laboratory Values

Appendix B Clinical Paths
Appendix C Cervical Dilation Chart
Appendix D Weight Conversion Charts
Appendix E Breast-Feeding and Medication Use
Appendix F Blood Pressure Charts for Children and Adolescents
Appendix G Growth Charts
Appendix H MyPlate
Appendix I Down Syndrome Healthcare Guidelines
Index
 Contents

About the Authors

Reviewers to the Third Edition
Preface

UNIT 1 INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING

CHAPTER 1 Perspectives on Maternal and Child Health Care
Introduction
Historical Development
The History of Maternal and Newborn Health and Health Care
The History of Child Health and Child Health Care
Evolution of Maternal and Newborn Nursing
Evolution of Pediatric Nursing
Health Status of Women and Children
Mortality
Childhood Mortality
Morbidity
Factors Affecting Maternal and Child Health
Family
Genetics
Society
Culture
Health Status and Lifestyle
Access to Health Care
Improvements in Diagnosis and Treatments
Empowerment of Health Care Consumers
Barriers to Health Care
Finances
Sociocultural Barriers
Health Care Delivery System Barriers
Legal and Ethical Issues in Maternal and Child Health Care
Abortion
Substance Abuse
Intrauterine Therapy
Maternal–Fetal Conflict
Stem Cell Research
Umbilical Cord Blood Banking
Informed Consent
Assent
Refusal of Medical Treatment
Advance Directives
Client Rights
Confidentiality
Implications for Nurses
CHAPTER 2 Family-Centered Community-Based Care
Introduction
Core Concepts of Maternal and Child Health Nursing
Family-Centered Care
Evidence-Based Care
Collaborative Care
Atraumatic Pediatric Care
Communication
Education
Discharge Planner and Case Manager
Client Advocate and Resource Manager
Preventative Care
Culturally Competent Nursing Care
Complementary and Alternative Medicine
Community-Based Care
Community Health Nursing
Community-Based Nursing
Shift in Responsibilities from Hospital-Based to Community-Based Nursing
Community-Based Nursing Interventions
Community-Based Nursing Challenges
Community-Based Nursing Care Settings for Women and Children
UNIT 2 WOMEN’S HEALTH THROUGHOUT THE LIFE SPAN
CHAPTER 3 Anatomy and Physiology of the Reproductive System
Female Reproductive Anatomy and Physiology
External Female Reproductive Organs
Internal Female Reproductive Organs
Breasts
Female Sexual Response
The Female Reproductive Cycle
Ovarian Cycle
Endometrial (Uterine) Cycle
Menstruation
Menstrual Cycle Hormones
Perimenopause
Menopause
Male Reproductive Anatomy and Physiology
External Male Reproductive Organs
Internal Male Reproductive Organs
Male Sexual Response
CHAPTER 4 Common Reproductive Issues
Introduction
Menstrual Disorders
Amenorrhea
Dysmenorrhea
Abnormal Uterine Bleeding
Premenstrual Syndrome
Endometriosis
Infertility
Cultural Considerations
Etiology and Risk Factors
Therapeutic Management
Nursing Assessment
Contraception
Types of Contraceptive Methods
Nursing Management of the Woman Choosing a Contraceptive Method
Nursing Assessment
Nursing Diagnoses
Nursing Interventions
Abortion
Surgical Abortion
Medical Abortion
Menopausal Transition
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 5 Sexually Transmitted Infections
Introduction
Sexually Transmitted Infections and Adolescents
Nursing Assessment
Nursing Management
Infections Characterized by Vaginal Discharge
Genital/Vulvovaginal Candidiasis (VVC)
Therapeutic Management
Nursing Assessment
Nursing Management
Trichomoniasis
Therapeutic Management
Nursing Assessment
Nursing Management
Bacterial Vaginosis
Therapeutic Management
Nursing Assessment
Nursing Management
Infections Characterized by Cervicitis
Chlamydia
Therapeutic Management
Nursing Assessment
Gonorrhea
Therapeutic Management
Nursing Assessment
Nursing Management of Chlamydia and Gonorrhea
Infections Characterized by Genital Ulcers
Genital Herpes Simplex
Therapeutic Management
 Nursing Assessment
Syphilis
Therapeutic Management
Nursing Assessment
Nursing Management of Herpes and Syphilis
Pelvic Inflammatory Disease
Therapeutic Management
Nursing Assessment
Nursing Management
Vaccine-Preventable STIs
Human Papillomavirus
Nursing Assessment
Therapeutic Management
Nursing Management
Hepatitis A and B
Therapeutic Management
Nursing Assessment
Nursing Management
Hepatitis C
Ectoparasitic Infections
Human Immunodeficiency Virus (HIV)
HIV and Adolescents
Clinical Manifestations
Diagnosis
Therapeutic Management
Nursing Management
Preventing Sexually Transmitted Infections
Behavior Modification
Contraception
CHAPTER 6 Disorders of the Breasts
Introduction
Benign Breast Disorders
Fibrocystic Breast Changes
Fibroadenomas
Mastitis
Malignant Breast Disorder
Pathophysiology
Staging of Breast Cancer
Risk Factors
Diagnosis
Therapeutic Management
Breast Cancer Screening
Nutrition
CHAPTER 7 Benign Disorders of the Female Reproductive Tract
Introduction
Pelvic Floor Disorders
Pelvic Organ Prolapse
Urinary Incontinence
Benign Growths
Polyps
Uterine Fibroids
Genital Fistulas
Bartholin Cysts
Ovarian Cysts
CHAPTER 8 Cancers of the Female Reproductive Tract
Introduction
Ovarian Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Endometrial Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Cervical Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
 Nursing Management
Vaginal Cancer
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Vulvar Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 9 Violence and Abuse
Introduction
Intimate Partner Violence
Incidence
Background
Characteristics of Intimate Partner Violence
Types of Abuse
Myths and Facts About Intimate Partner Violence
Abuse Profiles
Violence Against Pregnant Women
Violence Against Older Women
Nursing Management of Intimate Partner Violence Victims
Sexual Violence
Characteristics of Assailants
Sexual Abuse
Incest
Rape
Female Genital Cutting
Human Trafficking
Summary

UNIT 3 PREGNANCY
CHAPTER 10 Fetal Development and Genetics
Introduction
Fetal Development
Preembryonic Stage
Embryonic Stage
Fetal Stage
Fetal Circulation
Genetics
Advances in Genetics
Inheritance
Patterns of Inheritance for Genetic Disorders
Chromosomal Abnormalities
Genetic Evaluation and Counseling
Nursing Roles and Responsibilities
CHAPTER 11 Maternal Adaptation During Pregnancy
Introduction
Signs and Symptoms of Pregnancy
Subjective (Presumptive) Signs
Objective (Probable) Signs
Positive Signs
Physiologic Adaptations During Pregnancy
Reproductive System Adaptations
General Body System Adaptations
Changing Nutritional Needs of Pregnancy
Nutritional Requirements During Pregnancy
Gluten Free Diet During Pregnancy
Maternal Weight Gain
Nutrition Promotion
Special Nutritional Considerations
Psychosocial Adaptations During Pregnancy
Maternal Emotional Responses
Becoming a Mother
Pregnancy and Sexuality
Pregnancy and the Partner
Pregnancy and Siblings
CHAPTER 12 Nursing Management During Pregnancy
Introduction
Preconception Care
Risk Factors for Adverse Pregnancy Outcomes
 Nursing Management
The First Prenatal Visit
Comprehensive Health History
Physical Examination
Laboratory Tests
Follow-Up Visits
Follow-Up Visit Intervals and Assessments
Fundal Height Measurement
Fetal Movement Determination
Fetal Heart Rate Measurement
Teaching About the Danger Signs of Pregnancy
Assessment of Fetal Well-Being
Ultrasonography
Doppler Flow Studies
Alpha-Fetoprotein Analysis
Marker Screening Tests
Nuchal Translucency Screening
Amniocentesis
Chorionic Villus Sampling
Nonstress Test
Biophysical Profile
Nursing Management for the Common Discomforts of Pregnancy
First-Trimester Discomforts
Second-Trimester Discomforts
Third-Trimester Discomforts
Nursing Management to Promote Self-Care
Personal Hygiene
Clothing
Exercise
Sleep and Rest
Sexual Activity and Sexuality
Employment
Travel
Immunizations and Medications
Nursing Management to Prepare the Woman and her Partner for Labor, Birth, and Parenthood
Childbirth Education Classes
Nursing Management and Childbirth Education
Options for Birth Settings and Care Providers
Preparation for Breast-Feeding or Bottle-Feeding
Final Preparation for Labor and Birth

UNIT 4 LABOR AND BIRTH

CHAPTER 13 Labor and Birth Process
Introduction
Initiation of Labor
Premonitory Signs of Labor
Cervical Changes
Lightening
Increased Energy Level
Bloody Show
Braxton Hicks Contractions
Spontaneous Rupture of Membranes
True Versus False Labor
Factors Affecting the Labor Process
Passageway
Passenger
Powers
Position (Maternal)
Psychological Response
Philosophy
Partners
Patience
Patient (Client) Preparation: Prenatal Education
Pain Management
Physiologic Responses to Labor
Maternal Responses
Fetal Responses
Stages of Labor
First Stage
Second Stage
Third Stage
Fourth Stage
CHAPTER 14 Nursing Management During Labor and Birth
 Introduction
Maternal Assessment During Labor and Birth
Vaginal Examination
Assessing Uterine Contractions
Performing Leopold Maneuvers
Fetal Assessment During Labor and Birth
Analysis of Amniotic Fluid
Analysis of the FHR
Other Fetal Assessment Methods
Promoting Comfort and Providing Pain Management During Labor
Nonpharmacologic Measures
Pharmacologic Measures
Nursing Care During Labor and Birth
Nursing Management During the First Stage of Labor
Nursing Management During the Second Stage of Labor
Nursing Management During the Third Stage of Labor
Nursing Management During the Fourth Stage of Labor

UNIT 5 POSTPARTUM PERIOD

CHAPTER 15 Postpartum Adaptations
Introduction
Maternal Physiologic Adaptations
Reproductive System Adaptations
Cardiovascular System Adaptations
Urinary System Adaptations
Gastrointestinal System Adaptations
Musculoskeletal System Adaptations
Integumentary System Adaptations
Respiratory System Adaptations
Endocrine System Adaptations
Weight Loss After Childbirth
Cultural Considerations for the Postpartum Period
Balance of Hot and Cold
Postpartum Cultural Beliefs
Psychological Adaptations
Parental Attachment Behaviors
Maternal Psychological Adaptations
Partner Psychological Adaptations
CHAPTER 16 Nursing Management During the Postpartum Period
Introduction
Social Support and Cultural Considerations
Nursing Assessment in the Postpartum Period
Vital Signs Assessment
Physical Examination
Psychosocial Assessment
Nursing Interventions
Providing Optimal Cultural Care
Promoting Comfort
Assisting With Elimination
Promoting Activity, Rest, and Exercise
Preventing Stress Incontinence
Assisting With Self-Care Measures
Ensuring Safety
Counseling About Sexuality and Contraception
Promoting Maternal Nutrition
Supporting the Woman’s Choice of Infant Feeding Method
Teaching About Breast Care
Promoting Family Adjustment and Well-Being
Preparing for Discharge

UNIT 6 THE NEWBORN

CHAPTER 17 Newborn Transitioning
Introduction
Physiologic Transitioning
Cardiovascular System Adaptations
Respiratory System Adaptations
Body Temperature Regulation
Hepatic System Function
Gastrointestinal System Adaptations
Renal System Changes
Immune System Adaptations
Integumentary System Adaptations
Neurologic System Adaptations
 Behavioral Adaptations
Behavioral Patterns
Behavioral Responses
CHAPTER 18 Nursing Management of the Newborn
Introduction
Nursing Management During The Immediate Newborn Period
Assessment
Nursing Interventions
Nursing Management During The Early Newborn Period
Assessment
Nursing Interventions

UNIT 7 CHILDBEARING AT RISK

CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications
Introduction
Bleeding During Pregnancy
Spontaneous Abortion
Ectopic Pregnancy
Gestational Trophoblastic Disease
Cervical Insufficiency
Placenta Previa
Abruptio Placentae
Placenta Accreta
Hyperemesis Gravidarum
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Hypertensive Disorders of Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia and Eclampsia
HELLP Syndrome
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Gestational Diabetes
Blood Incompatibility
Pathophysiology
Nursing Assessment
Nursing Management
Amniotic Fluid Imbalances
Polyhydramnios
Oligohydramnios
Multiple Gestation
Therapeutic Management
Nursing Assessment
Nursing Management
Premature Rupture of Membranes
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations
Introduction
Diabetes Mellitus
Pathophysiology
Screening
Therapeutic Management
Nursing Assessment
Nursing Management
Cardiovascular Disorders
Congenital and Acquired Heart Disease
Hypertension in Pregnancy
Chronic Hypertension
Respiratory Conditions
Asthma
Tuberculosis
Hematologic Conditions
Iron-Deficiency Anemia
Thalassemia
Sickle Cell Anemia
Autoimmune Disorders
 Systemic Lupus Erythematosus
Multiple Sclerosis
Rheumatoid Arthritis
Infections
Cytomegalovirus
Rubella
Herpes Simplex Virus
Hepatitis B Virus
Varicella Zoster Virus
Parvovirus B19
Group B Streptococcus
Toxoplasmosis
Women Who Are HIV Positive
Vulnerable Populations
Pregnant Adolescent
The Advanced Maternal Age Woman
The Obese Pregnant Woman
The Pregnant Woman and Substance Abuse
CHAPTER 21 Nursing Management of Labor and Birth at Risk
Introduction
Dystocia
Problems with the Powers
Problems with the Passenger
Problems with the Passageway
Problems with the Psyche
Nursing Assessment
Alternative/Nontraditional Families
Preterm Labor
Therapeutic Management
Nursing Assessment
Nursing Management
Postterm Pregnancy
Nursing Assessment
Nursing Management
Women Requiring Labor Induction and Augmentation
Therapeutic Management
Nursing Assessment
Nursing Management
Vaginal Birth After Cesarean
Intrauterine Fetal Demise
Nursing Assessment
Nursing Management
Women Experiencing an Obstetric Emergency
Umbilical Cord Prolapse
Placenta Previa
Placental Abruption
Uterine Rupture
Amniotic Fluid Embolism
Women Requiring Birth-Related Procedures
Amnioinfusion
Forceps- or Vacuum-Assisted Birth
Cesarean Birth
CHAPTER 22 Nursing Management of the Postpartum Woman at Risk
Introduction
Postpartum Hemorrhage
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Venous Thromboembolic Conditions
Pathophysiology
Nursing Assessment
Nursing Management
Postpartum Infection
Metritis
Surgical Site Infections
Urinary Tract Infections
Mastitis
Postpartum Affective Disorders
Postpartum Blues
Postpartum Depression
Postpartum Psychosis
UNIT 8 THE NEWBORN AT RISK
CHAPTER 23 Nursing Care of the Newborn with Special Needs
Introduction
Birthweight Variations
Small-for-Gestational-Age Newborns
Large-for-Gestational-Age Newborns
Gestational Age Variations
Postterm Newborn
Preterm Newborn
Late Preterm Newborn (“Near Term”)
Dealing With Perinatal Loss
CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions
Introduction
Acquired Disorders
Perinatal Asphyxia
Transient Tachypnea of the Newborn
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Persistent Pulmonary Hypertension of the Newborn
Periventricular-Intraventricular Hemorrhage
Necrotizing Enterocolitis
Infants of Diabetic Mothers
Birth Trauma
Newborns of Substance-Abusing Mothers
Hyperbilirubinemia
Congenital Conditions
Esophageal Atresia and Tracheoesophageal Fistula
Omphalocele and Gastroschisis
Anorectal Malformations
Bladder Exstrophy

UNIT 9 HEALTH PROMOTION OF THE GROWING CHILD AND FAMILY

CHAPTER 25 Growth and Development of the Newborn and Infant
Physical Growth
Weight
Height
Head Circumference
Organ System Maturation
Neurologic System
Respiratory System
Cardiovascular System
Gastrointestinal System
Genitourinary System
Integumentary System
Hematopoietic System
Immunologic System
Psychosocial Development
Cognitive Development
Motor Skill Development
Gross Motor Skills
Fine Motor Skills
Sensory Development
Sight
Hearing
Smell and Taste
Touch
Communication and Language Development
Social and Emotional Development
Stranger Anxiety
Separation Anxiety
Temperament
Cultural Influences on Growth and Development
Promoting Healthy Growth and Development
Promoting Growth and Development Through Play
Promoting Early Learning
Promoting Safety
Promoting Nutrition
Promoting Healthy Sleep and Rest
Promoting Healthy Teeth and Gums
Promoting Appropriate Discipline
Addressing Child Care Needs
Addressing Common Developmental Concerns
Colic
 Spitting Up
Thumb Sucking, Pacifiers, and Security Items
Teething
CHAPTER 26 Growth and Development of the Toddler
Physical Growth
Organ System Maturation
Neurologic System
Respiratory System
Cardiovascular System
Gastrointestinal System
Genitourinary System
Musculoskeletal System
Psychosocial Development
Cognitive Development
Motor Skill Development
Gross Motor Skills
Fine Motor Skills
Sensory Development
Communication and Language Development
Emotional and Social Development
Separation Anxiety
Temperament
Fears
Moral and Spiritual Development
Cultural Influences on Growth and Development
The Nurse’s Role in Toddler Growth and Development
Promoting Healthy Growth and Development
Promoting Growth and Development Through Play
Promoting Early Learning
Promoting Safety
Promoting Nutrition
Promoting Healthy Sleep and Rest
Promoting Healthy Teeth and Gums
Promoting Appropriate Discipline
Addressing Common Developmental Concerns
Toilet Teaching
Negativism
Temper Tantrums
Thumb Sucking and Pacifiers
Sibling Rivalry
Regression
CHAPTER 27 Growth and Development of the Preschooler
Physical Growth
Organ System Maturation
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Gross Motor Skills
Fine Motor Skills
Sensory Development
Communication and Language Development
Emotional and Social Development
Friendships
Temperament
Fears
Cultural Influences on Growth and Development
Promoting Healthy Growth and Development
Promoting Growth and Development Through Play
Promoting Early Learning
Promoting Language Development
Choosing a Preschool/Starting Kindergarten
Promoting Safety
Safety in the Water
Promoting Nutrition
Promoting Healthy Sleep and Rest
Promoting Healthy Teeth and Gums
Promoting Appropriate Discipline
Addressing Common Developmental Concerns
Lying
Sex Education
Masturbation
CHAPTER 28 Growth and Development of the School-Age Child
 Physical Growth
Organ Systems Maturation
Neurologic System
Respiratory System
Cardiovascular System
Gastrointestinal System
Genitourinary System
Prepubescence
Musculoskeletal System
Immune System
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Gross Motor Skills
Fine Motor Skills
Sensory Development
Communication and Language Development
Emotional and Social Development
Temperament
Self-Esteem Development
Body Image
School-Age Fears
Peer Relationships
Teacher and School Influences
Family Influences
Cultural Influences On Growth and Development
The Nurse’s Role in School-Age Growth and Development
Promoting Healthy Growth and Development
Promoting Growth and Development Through Play
Promoting Learning
Promoting Safety
Abuse in Children
Promoting Nutrition
Promoting Healthy Sleep and Rest
Promoting Healthy Teeth and Gums
Promoting Appropriate Discipline
Addressing Common Developmental Concerns
Television, Video Games, and the Internet
School Refusal
Latchkey Children
Stealing, Lying, and Cheating
Bullying
Tobacco and Alcohol Education
CHAPTER 29 Growth and Development of the Adolescent
Physiologic Changes Associated with Puberty
Physical Growth
Organ System Maturation
Neurologic System
Respiratory System
Cardiovascular System
Gastrointestinal System
Musculoskeletal System
Integumentary System
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Gross Motor Skills
Fine Motor Skills
Communication and Language Development
Emotional and Social Development
Relationship with Parents
Self-Concept and Body Image
Importance of Peers
Sexuality and Dating
Cultural Influences on Growth and Development
Promoting Healthy Growth and Development
Promoting Growth and Development Through Sports and Physical Fitness
Promoting Learning
Promoting Safety
Promoting Nutrition
Promoting Healthy Sleep and Rest
 Promoting Healthy Teeth and Gums
Promoting Personal Care
Promoting Appropriate Discipline
Promoting Proper Media Use
Addressing Common Developmental Concerns
Violence
Substance Use

UNIT 10 FOUNDATIONS OF PEDIATRIC NURSING

CHAPTER 30 Atraumatic Care of Children and Families
Preventing/Minimizing Physical Stressors
Utilizing the Child Life Specialist
Minimizing Physical Stress During Procedures
Preventing or Minimizing Child and Family Separation: Providing Child- and Family-Centered Care
Promoting A Sense of Control
Enhancing Communication
Teaching Children and Families
CHAPTER 31 Health Supervision
Principles of Health Supervision
Wellness
Medical Home
Partnerships
Special Issues in Health Supervision
Components of Health Supervision
Developmental Surveillance and Screening
Injury and Disease Prevention
Health Promotion
CHAPTER 32 Health Assessment of Children
Health History
Preparing for the Health History
Performing a Health History
Physical Examination
Preparing for the Physical Examination
Steps of the Physical Examination
Performing a Physical Examination
CHAPTER 33 Caring for Children in Diverse Settings
Children’s Reactions to Hospitalization
Factors Affecting Children’s Reaction to Hospitalization
Family’s Reactions to the Child’s Hospitalization
The Nurse’s Role in Caring for the Hospitalized Child
Community Care in Childhood
CHAPTER 34 Caring for the Special Needs Child
The Medically Fragile Child
Impact of the Problem
Effects of Special Needs on the Child
Effects on the Family
Nursing Management of the Medically Fragile Child and Family
The Dying Child
End-of-Life Decision Making
Nursing Management of the Dying Child
CHAPTER 35 Key Pediatric Nursing Interventions
Medication Administration
Differences in Pharmacodynamics and Pharmacokinetics
Developmental Issues and Concerns
Determination of Correct Dose
Oral Administration
Rectal Administration
Ophthalmic Administration
Otic Administration
Nasal Administration
Intramuscular Administration
Subcutaneous and Intradermal Administration
Intravenous Administration
Providing Atraumatic Care
Educating the Child and Parents
Preventing Medication Errors
Intravenous Therapy
Sites
Equipment
Inserting Peripheral IV Access Devices
IV Fluid Administration
Preventing Complications
Discontinuing the IV Device
 Providing Nutritional Support
Enteral Nutrition
Parenteral Nutrition
CHAPTER 36 Pain Management in Children
Physiology of Pain
Transduction
Transmission
Perception
Modulation
Types of Pain
Classification by Duration
Classification by Etiology
Classification by Source or Location
Factors Influencing Pain
Age and Gender
Cognitive Level
Temperament
Previous Pain Experiences
Family and Culture
Situational Factors
Developmental Considerations
Infants
Toddlers
Preschoolers
School-Age Children
Adolescents
Common Fallacies and Myths About Pain in Children
Management of Pain
Nonpharmacologic Management
Pharmacologic Management
Management of Procedure-Related Pain
Management of Chronic Pain

UNIT 11 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER

CHAPTER 37 Nursing Care of the Child With an Infectious or Communicable Disorder
Infectious Process
Fever
Stages of Infectious Disease
Chain of Infection
Preventing the Spread of Infection
Variations in Pediatric Anatomy and Physiology
Common Medical Treatments
Sepsis
Bacterial Infections
Community-Acquired Methicillin-Resistant Staphylococcus Aureus
Scarlet Fever
Diphtheria
Pertussis
Tetanus
Botulism
Osteomyelitis
Septic Arthritis
Viral Infections
Viral Exanthems
Mumps
Zoonotic Infections
Cat-Scratch Disease
Rabies
Lyme Disease
Rocky Mountain Spotted Fever
Parasitic and Helminthic Infection
CHAPTER 38 Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder
Variations in Pediatric Anatomy and Physiology
Brain and Spinal Cord Development
Nervous System
Head Size
Common Medical Treatments
Seizure Disorders
Epilepsy
Nursing Management
Febrile Seizures
Neonatal Seizures
Structural Defects
 Neural Tube Defects
Microcephaly
Chiari Malformation
Hydrocephalus
Intracranial Arteriovenous Malformation
Craniosynostosis
Positional Plagiocephaly
Infectious Disorders
Bacterial Meningitis
Aseptic Meningitis
Encephalitis
Reye Syndrome
Trauma
Head Trauma
Nonaccidental Head Trauma
Near-Drowning
Blood Flow Disruption
Cerebral Vascular Disorders (Stroke)
Chronic Disorders
Headaches
Breath Holding
CHAPTER 39 Nursing Care of the Child With an Alteration in Sensory Perception/Disorder of the Eyes or Ears
Variations in Pediatric Anatomy and Physiology
Eyes
Ears
Common Medical Treatments
Infectious and Inflammatory Disorders of the Eyes
Conjunctivitis
Nasolacrimal Duct Obstruction
Eyelid Disorders
Periorbital Cellulitis
Eye Injuries
Visual Disorders
Refractive Errors
Astigmatism
Strabismus
Amblyopia
Nystagmus
Infantile Glaucoma
Congenital Cataract
Retinopathy of Prematurity
Visual Impairment
Infectious and Inflammatory Disorders of the Ears
Acute Otitis Media
Otitis Media with Effusion
Otitis Externa
Hearing Loss and Deafness
CHAPTER 40 Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder
Variations in Pediatric Anatomy and Physiology
Nose
Throat
Trachea
Lower Respiratory Structures
Chest Wall
Metabolic Rate and Oxygen Need
Common Medical Treatments
Acute Infectious Disorders
Common Cold
Sinusitis
Influenza
Pharyngitis
Tonsillitis
Infectious Mononucleosis
Laryngitis
Croup
Epiglottitis
Bronchiolitis
Pneumonia
Bronchitis
Tuberculosis
Acute Noninfectious Disorders
Epistaxis
Foreign Body Aspiration
Another random document with
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 Fig. 42. A transsection through the posterior region of the œsophagus of the
hibernating animal, under low magnification; e, epithelium; cm, circular muscles;
lm, longitudinal muscles; mm, muscularis mucosa; sm, submucosa; s, serosa.

In the posterior region of the œsophagus, as may be seen by

comparison of figures 41 and 42, the wall as a whole is about one
third thicker than in the anterior region just described, though how
much of this difference is due to different degrees of distension or
contraction it is hard to say.
The epithelium, e, is in the tissue studied thrown into less
complicated folds than in the anterior region, and is not so thick.
The submucosa, sm, if the entire layer may be so called, has
about the same thickness and structure as in the more anterior
region; but instead of the small and widely scattered bundles of
longitudinal muscle fibers there is a distinct layer of muscle which
may be called the muscularis mucosa, mm, lying about midway
between the epithelium and the circular muscle layer.
The muscularis mucosa is somewhat variable in thickness and is
thrown into folds that correspond to the larger folds of the epithelium
and the submucosa; one of these folds is shown in Figure 42. The
fibers of the muscularis mucosa are apparently all longitudinal in
position.
Outside of the submucosa is a layer of circular muscle fibers, cm;
it is here somewhat wider and more dense than in the anterior
region.
The longitudinal muscle layer (Fig. 42, lm) is much wider and more
compact than in the anterior region. The fibers are indistinctly divided
into large irregular masses as shown in the figure.
The serosa (Fig. 42, s) is a varying but fairly thick layer that is
quite distinct from the longitudinal muscle layer. It consists of the
usual connective tissue groundwork with scattered blood-vessels.
The epithelium, as was said above, is thicker and somewhat more
folded in the anterior than in the posterior region, and in the former
region is partially ciliated while in the latter cilia are entirely wanting.
With these exceptions the epithelium is practically the same in the
two regions.
 Figure 43 represents the epithelium from the anterior region as
seen under high magnification. The outlines of all the cells could not
be determined but if each nucleus represents a cell there are twenty-
five or thirty layers of cells. The nuclei are arranged in two dense,
irregular groups, one along the base of the epithelium, the other
about two thirds of the distance from the base to the free border. The
basal nuclei are perhaps slightly larger and more rounded than those
of the distal group. Between these two groups are numerous more
scattered nuclei; while scattered through the epithelium, except near
the free border, are smaller, round nuclei that stain somewhat darker
than the rest; these, from their size and appearance, seem possibly
to belong to an invisible network of connective tissue that has
penetrated the epithelium from the surrounding mucosa.
 Fig. 43. The epithelium of the anterior region of the œsophagus of the
hibernating animal, under high magnification.

The free border of the epithelium consists of long, ciliated,

columnar cells in which the cell walls may be easily seen. The cilia
are of average length and even in this anterior region are not
everywhere present; possibly they are arranged in bands, but the
material at hand was not sufficient to determine this. As was noted
above, cilia are wanting in the posterior region.
The only differences noted in the anterior region of the
œsophagus between the feeding and the hibernating conditions are
in the muscularis mucosa and the epithelium. As was noted above,
the muscularis mucosa is practically absent in the hibernating stage,
being represented only by a few small, scattered bundles of
longitudinal muscle fibers; while in the feeding stage there is a
narrow but fairly distinct layer to represent the muscularis mucosa.
 Fig. 44. The epithelium of the anterior region of the œsophagus of
the feeding animal, under high magnification.

The difference in the appearance of the epithelium is not striking.

The nuclei are somewhat larger in the feeding stage and, instead of
being crowded into a basal and a median zone, as noted in the
hibernating conditions, they form a dense basal zone, but show no
indication of medial zone. From the dense basal zone the nuclei
become more scattered towards the free surface and are rarely
found closer to the surface than is shown in Figure 44. The smaller
nuclei scattered among the larger ones, noted in connection with the
hibernating stage, are not here seen.
As in the hibernating stage cilia are present on some but not all
cells of this region.
The only noticeable difference between the feeding and
hibernating conditions of the posterior region of the œsophagus is in
the epithelium, which, as in the feeding condition of the anterior
œsophagus, exhibits but one zone of closely set nuclei, that at the
base of the epithelium.
The Stomach. The stomach was sectioned in three regions, as
shown in Figure 35: (1) in the cardiac region very near the opening
of the œsophagus; (2) in the middle or fundic region; and (3) in the
region near the opening of the pylorus. The first two sections are in
the first or large region of the stomach; the third section is in the
second or small region of the stomach (Fig. 35).
The wall as a whole is thickest in the fundus, being there
practically twice as thick as in the pyloric and half again as thick as in
the cardiac region. This great thickening is due mainly to a
thickening of the middle or oblique layer of muscle, which is here
remarkably developed. The mucosa is of nearly uniform thickness in
the different regions and will be described later.
Since there is no striking difference beside that of thickness in the
general structure of the wall of the different regions, the pyloric
region, as seen under low magnification, will now be described (Fig.
45).
 The mucosa, m, consists of fairly long glands underlaid by a well-
marked muscularis mucosa, mm, the latter exhibiting a compact
circular layer over a wider but more scattered layer of longitudinal
fibers. A considerable amount of fibrous connective tissue lies
among the muscle fibers. The circular layer of the muscularis
mucosa sends towards the surface numerous strands or septa
between the glands; six or eight of these are seen in the figure.
These strands are not nearly so numerous in the large region of the
stomach. As was said, the outer or longitudinal layer of the
muscularis mucosa is wider but less compact than the circular and
its bundles of fibers are seen in the figure as a layer of large,
scattered dots just beneath the circular layer.
The submucosa, sm, is of average thickness and density. In the
fundic and cardiac regions it seems to extend between the circular
and oblique layers; at any rate, there is a considerable layer of
connective tissue between these two muscular layers.
The circular muscular layer, cm, is of only moderate thickness and
is of rather a loose character. In the pyloric region it is not very
distinct from the underlying oblique layer, but in the other regions, as
has just been said, it is separated from the oblique layer by a
considerable layer of connective tissue like that of the submucosa.
The oblique layer, om, even in this section of the pyloric region is
the thickest of the three muscle layers; while in the cardiac, and
especially in the fundic, regions it is of great thickness, as was noted
above, and is made up of larger bundles with less intervening
connective tissue.
 Fig. 45. A transsection through the wall of the
pyloric region of the stomach of the feeding animal,
under low magnification; m, mucosa; om, oblique
muscles; other letters as in Figure 42.
 The outer or longitudinal muscle layer, lm, is comparatively little
developed and consists of small rather scattered bundles of muscles
with a correspondingly large amount of connective tissue. This
connective tissue passes insensibly into that of the surrounding
serosa, s, a loose, vascular layer of varying thickness and density,
shown very thick in Figure 45, but often much thinner.
So far as could be determined, the mucous membrane has the
same structure in both anterior and middle regions of the stomach.
That of the pyloric or small region, although fixed, stained, et cetera,
just as carefully as the rest, did not show cell details sufficiently well
to draw; the ducts of the glands in this region are fairly distinct but
the deeper parts of the glands have the appearance of series of
alveoli or large adipose cells. What the significance of this condition
may be the writer is not able to say, but since the structure of this
region of the gastric mucous membrane is not clear no attempt will
be made to describe its appearance under higher magnification than
was employed in the figure above. However, as will be noted below,
there is probably no great difference between the pyloric mucosa
and that of the other regions of the stomach.
 Fig. 46. The glands of the middle or fundic region of the stomach of the
hibernating animal, under high magnification; A, through duct; B, through body of
gland; C, through fundus of gland.
 Figure 46 shows portions of typical glands from the mucosa of the
middle region of the stomach, the posterior border of the large
stomach cavity; A is a longitudinal section through two ducts where
they open to the surface; B is a similar section through the body of a
gland below the region of the duct; C is a transsection through the
bottom or fundus of a gland; all are drawn with a camera under the
same magnification.
As is seen in Figure 45, under low magnification, the duct is about
one third of the entire length of the gland. The lumen of the duct is
fairly wide, that of the body of the gland is reduced to a mere slit,
while that of the fundus is quite wide.
One, two, or possibly more, glands may open to the surface
through one duct, as is shown in Figure 46. There is nothing peculiar
about the epithelium of these glands. Near the opening of the duct
the cells are of a typical columnar character with finely granular
cytoplasm, each with a nucleus at its basal end.
In the deeper parts of the duct the cells become shorter until in the
body of the gland (Fig. 46, B) they are cuboidal in outline.
The bodies of the glands are so closely packed together that it is
difficult to pick out an individual tube that will show details clearly
enough to draw with a camera lucida. So far as could be observed
all of the cells of this region of the gland are alike.
The bottom or fundus of the gland, as seen in Figure 46, C, is
somewhat enlarged and has a wide lumen. The cells are of the same
general character as in the more distal parts of the gland except that
they are somewhat more columnar or pyramidal than in the body of
the gland. The nuclei of the body and fundus are usually somewhat
larger and more nearly spherical than in the columnar cells of the
duct.
The feeding animals from which tissues were taken were
considerably smaller than the hibernating specimen, so that the
stomach walls were proportionately thinner; but, so far as could be
discovered, there was no difference in structure.
The relative thickness of the entire wall in each of the three
regions sectioned was about the same as described above.
As has been said, the mucosa on the pyloric or small region of the
stomach from the hibernating animal was so poorly fixed that its
structure could not be made out. In the feeding stage the mucosa of
this region was as well fixed as any of the other tissues and showed
that its structure is essentially like that shown in Figure 46, except
that the glands are proportionately not quite so long as in the fundic
and cardiac regions, and are somewhat more open—that is, they
have wider lumina; their lining cells are all of one kind and are
unchanged from what was seen in the hibernating condition.
The Small Intestine. Three regions of the small intestine will be
described: (1) an anterior, just caudad to the stomach; (2) a middle;
and (3) a posterior, one half inch cephalad to the rectum or large
intestine (Fig. 35).
As might be expected, the general structure of the wall of the
intestine is essentially the same in all three regions, the slight
differences noticeable being due mainly to variations in the thickness
of the various layers.
The middle and posterior regions have about the same diameter,
while the diameter of the anterior region is considerably greater, due
partly to the greater diameter of the lumen but mainly to the greater
thickness of the constituent layers, especially the mucosa. The
mucosa is also thrown into more numerous and complicated folds in
the anterior than in the middle and posterior regions; the complexity
of the mucosa seems to diminish as the intestine is followed caudad.
In the anterior region the mucosa may form at least one half of the
entire thickness of the wall, while in the posterior region it may form
less than one third of the thickness of the intestinal wall. The minute
structure of the intestinal epithelium will be described below.
The chief peculiarity of the intestinal wall is the apparent total
absence of a submucosa (Fig. 47). As will be described later, the
mucosal epithelium is laid upon the usual bed of fibrous and
lymphatic tissue, the tunica propria (Fig. 47, tp).
At the outer border of the tunica propria, and with no tissue
corresponding to a submucosa between it and the circular muscular
layer, is a thin and indistinct layer that has the appearance of a
longitudinal layer of muscle fibers; this should correspond to the
muscularis mucosa (Figs. 47, 48, 49, and 51, mm).
 Fig. 47. A transsection of the wall of the anterior region of the small intestine of
the hibernating animal, under low magnification; ln, lymph node; tp, tunica propria;
other letters as in Figure 42.

The circular, cm, and longitudinal, lm, muscle layers are compact,
and are distinct from the other layers of the wall; the former is
approximately twice the thickness of the latter. The relative thickness
of all the layers in the three regions of the intestine may be seen by
comparing Figures 47, 48, and 49.
 Fig. 48. An outline of a transsection of the wall of the middle
region of the small intestine of the hibernating animal, under low
magnification; lettering as in Figure 42.

The serosa, s, which is of about the same character in the three

regions under discussion, is a distinct and fairly dense layer of
connective tissue with numerous blood-vessels.
The general appearance of the mucous membrane as a whole is
sufficiently clear in the low-power drawing described above, so that
all that need be shown under a higher magnification is the epithelium
(Fig. 50). The upper part of this figure represents the lower end of
one of the intestinal glands cut longitudinally, below which is the end
of another gland in transverse section. Between the two sections is
the compact tunica propria of lymphatic tissue.
The section from which this particular figure was drawn was in the
anterior region, but the corresponding part of a section in either of
the other regions would have practically the same appearance.
The epithelium is of the stratified columnar type. The superficial
cells are very tall and narrow, with the nuclei generally at or near the
bases, though an occasional nucleus may be seen near the free end
of a cell. Below the tall columnar cells are four or five rows of nuclei
which represent smaller, irregular cells, though the cell walls could
not always be determined between the closely packed nuclei. No
goblet cells are to be seen at any place.

Fig. 49. An outline of a transsection through the

wall of the posterior region of the small intestine of the
hibernating animal, under low magnification; lettering
as in Figure 42.
 The relative diameters of the three regions of the small intestine in
the feeding condition are about the same as noted for the
hibernating stage; that is, the anterior region has the greatest
diameter and the other regions are smaller and have about the same
average diameter.
The most marked difference between the intestine during
hibernation and feeding is in the relative thickness of the mucosa
and muscular layers. As described for the hibernating stage, so in
the feeding stage, the mucosa is relatively the thickest in the anterior
regions and diminishes in thickness caudad; but while, in the
hibernating stage, it forms, in the anterior region, as much as half of
the entire thickness of the wall, in the feeding condition it forms, in
the same region, at least two thirds of the entire wall and in the
middle and posterior regions more than half of the wall.
 Fig. 50. Part of the mucous membrane of the anterior region of
the small intestine of the hibernating animal, under high
magnification. The upper part of the figure shows a part of a gland
cut longitudinally, the lower part of the figure shows another gland
cut transversely; e, epithelium; tp, tunica propria.
 The feeding animals being the smaller, the diameter of the
intestine was considerably less than in the hibernating stage; but the
actual thickness of the mucosa was practically the same, so that the
difference in diameter was due to the difference in the thickness of
the muscular and fibrous layers. It is therefore probable that the
differences noted above are due rather to the differences in the size
of the animals from which the tissues were taken than to the different
conditions of hibernation and feeding. The point to be noticed is that
the increase in the diameter of the intestine is due almost if not
entirely to an increase in thickness of the connective tissue and
muscle layers.
No difference in the complexity of the folds of the mucosa of the
two stages can be noticed.
The thickness of the fibro-muscular part of the wall of the intestine
varies considerably on different sides of the same region, but it
consists of the same layers in about the same relative amounts.
 Fig. 51. An outline of a transsection of the wall of
the middle region of the small intestine of the feeding
animal, under low magnification; m, mucosa; other
letters as in Figure 42.
 Figure 51 represents in outline the wall of the middle region of the
small intestine during feeding.
The epithelium is of the same thickness in the two stages, and the
only difference in its character that can be seen under a high
magnification is that, in the middle region at least, the nuclei are not
crowded so close together at the basal ends of the cells as in the
hibernating stage but are scattered more towards their free ends.