Exam 1 Study Guide

Nutritional importance for pregnant women

- Well-balanced diet include ALL food groups
- Encourage adequate fluid intake for exchange of nutrients
and waste
- Should NOT eat big meals “for two”
o Encourage frequent small meals to decrease n/v
- Vegan diets do not contain sufficient amount of B12, B6,
calcium, and zinc.
o Vital to take prenatal vitamins and consume fortified
food to meet nutritional demands during pregnancy.
- 24 hour recall 1 priority when assessing nutritional intake
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and need for education

- What to eat:
o Sea Fish
o Lean meats
o Nuts, beans, lentils
o Legumes
o Cooked eggs
o Leafy veggies
o Whole grains
o Yogurt
o Sweet Potatoes
o Avocados
o Soybeans

- What NOT to eat

o Raw or undercooked foods
 ▪ Sushi
▪ Raw eggs
▪ Undercooked steak
o Soft cheese
o Pate
o Excessive caffeine
o Alcohol
o Raw milk
o Smoked seafood

- Recommended Vitamins/ Supplements

o Iodine
▪ 150mcg daily
o Folic acid/Folate
▪ 400mcg daily
▪ Decreases risk of
• Newborn spina bifida
• Newborn neural tube defects
• Cleft palate/cleft lip
o Iron
▪ Meats
▪ Legumes
▪ Eggs
▪ Dried fruit
▪ Peas
▪ Green leafy veggies
▪ Iron fortified cereal/bread
o Calcium
▪ Dairy
▪ Salmon
▪ Tofu
▪ Green leafy veggies
▪ Calcium fortified OJ
 ▪ Sardines
▪ Dried beans
o Vitamin D
▪ Sunlight
▪ Egg yolk
▪ Fish oils
▪ Vitamin D fortified foods
Nutritional concerns during pregnancy
- Nausea/vomiting
o Malnutrition
o Dehydration
o Hypovolemic shock
o Electrolyte imbalance
o Education
▪ Small frequent meals every 2-3hrs throughout the
day
▪ Drink fluids in between meals and not with meals
▪ Eat a bedtime protein snack to maintain glucose
levels at night
▪ Eat crackers in the morning to reduce nausea
▪ Adequate fluid intake to remain hydrated
▪ Administration of antiemetic as per the provider’s
request
- Anemia
o Hgb and hct decreases due to dilution.
▪ during the 2 trimester levels decrease due to
nd

increased absorption of iron in GI tract for fetal

nutrient supply
o Considered anemic if below 10.5
o Education
▪ Eat iron fortified foods
▪ Routine blood work
- Food Cravings
 o Pica
▪ Consumption of nonnutritive substances which
causes:
• Malnutrition
• Electrolyte imbalances
▪ Common substances include clay, chalk, dirt, ice,
coffee grounds, toothpaste etc.

Weight Gain in Pregnancy

- Underweight (BMI < 18.5): 28lbs – 40lbs
- Normal weight (BMI 18.5 – 24.9): 25lbs – 35lbs
- Overweight (BMI 25 – 29.9): 15lbs – 25lbs
- Obese (BMI > 30): 11lbs – 20lbs)
o Higher risk for:
▪ Spontaneous abortions
▪ Gestational diabetes
▪ Gestational HTN
▪ Preeclampsia
▪ Prolonged births
▪ Cesareans
▪ Postpartum hemorrhage
- Overweight and obese women are encouraged to lose weight
prior to pregnancy
- Weight gain patterns throughout pregnancy (confirm)
o 1 trimester: 1.1lb – 4.4lb (0.5 – 2kg)
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o 2 trimester: 1lb
nd

o 3 trimester: 1lb
rd

Socioeconomic Factors
- Transportation
 - Education
- Employment
- Access to supermarkets
- Health Insurance

Patient Education
- Prenatal visits/care
- Ultrasounds
- Placenta location, position of fetus
- Labs
o CBC
2030 Healthy People Initiative
- Goal is to have healthy pregnancy
- Implementation of cultural diversity
- Minimize maternal death
- Minimize pregnancy complications

Holistic Teaching methods to treat Pregnant women

- Yoga
- Aromatherapy
- Acupuncture
- Guided Imagery
- Meditation

Technological advancements to support pregnancy

- Dopplers
- 3D images

Spousal Support/ Family Support

- Educate on how to support during pregnancy
o Family sometimes involved in care of child
- Treat surrogate as if they are the biological mother
o Justice
o Beneficence
 - Childbirth effects the entire family
- Include in education
- Encourage family group therapy
- Encourage family to visit hospital prior to delivery
- Child birth classes
- Include culture in car of patient and family

Intimate Partner Violence

- Physical, emotional, or sexual abuse from a current or
former partner
- Abuser tends to blame victim for abuse tendencies
- Victim emotions
o Embarrassed
o Ashamed
o Powerlessness
o Loss of self-respect
- Can happen to anybody, but typically affect households of:
o Low income
o Drug abuse
o Depression
o History of abuse
- Can cause health problems for both the mother and fetus due
to added stress

Role of NP
- Performs prenatal/newborn care
- Does NOT perform deliveries
- Can assist with deliveries

Doula/Midwife
- Must be certified to be doula
o Are able to deliver babies ONLY at home
o Mother needs to sign consent stating that is her wish
 o Needs physician on standby during birth in the event
something goes wrong they can assist
- Coach during delivery in a hospital do NOT deliver babies
at hospital

Government Agencies
- Planned Parenthood
- Leaning towards LDRP
o Entire delivery and care of mom and baby done in one
room
o Considered Family Centered Care facilities

Legal/Ethical issues
- Mom can decline doppler/fetal monitoring
o Educate importance of fetal monitoring
o Notify physician if mom declines

Perinatal Core measures as per the joint commission (TJC)

- Standard care by trying to decrease
- c -sections
- elective deliveries
o Can deliver prior to 40 weeks
- Advocating for the patient

Length of stay
- Vaginal delivery 48hrs
- Cesarean 96hrs

Roles for nurses in maternity care

- Positive feedback
- Repetition
- Role modeling
o How to swaddle
 - Address conflict and frustration
o e.g mother blaming self for premature baby
- Discharge teaching
o Starts upon admission
o Requires documentation of teaching
o Document education first so you don’t forget what
was discussed

Dental Care
- Increase in progesterone and estrogen:
o Cause inflammation of gums
o Infection of gums due to hormonal changes

Conception and Prenatal development

- Fertilized Egg à Zygote à Embryo à Fetus
- Major organs developed by week 8
o Heart
o Spinal cord
o Brain
- Placenta is organ responsible for exchange of
nutrients/gas/waste.
o Occurs at site of chorionic villi
- Fetal membranes/Amniotic Fluids
o Amniotic membranes:
▪ protect the fetus and prenatal development
▪ Maintains temperature
o Umbilical Cord
▪ Two arteries
▪ One vein
Signs of Pregnancy
- Presumptive
o Amenorrhea (absent period)
 o n/v
o Urinary Frequency
o Breast changes (tenderness, swelling, darkening
areolae)
o Quickening
▪ Slight fluttering movements of the fetus felt by
patient (16 – 20 weeks of gestation)
- Probable
o Hegar’s sign: softening and compressibility of lower
uterus
o Positive pregnancy test (HCG/UCG)
▪ hcG can be detected as early as 7 – 8 days prior to
expected menses
▪ UCG tests should be done on a first-voided
morning specimen
o Goodell’s sign (softening of cervical tip)
o Chadwick’s sign (Increased vascularity noted on
pelvic exam)
o Ballotment (rebounding of fetus)
o Abdominal enlargement
o Palpation of fetal outline
- Positive
o Visualization of pregnancy on US
o Prescence of fetal heartbeat
o Fetal movement palpated by examiner
- All major organs approx. 8 weeks after fertilization
o Birth defects develop around this time
o Embryo is vulnerable to teratogenic agents

Assessments for Initial Visit

Nagele’s Rule
- Nagele’s Rule: Take the first day of the LMP, subtract 3
 months, and then add 7 days. Add 1 year to adjust for the
year when appropriate.
- Measurement of fundal height
o In cm, measure from the symphysis pubis to uterine
fundus
o Approximates the gestational age
o Bladder should be emptied to avoid elevation of
uterus
- Obtain reproductive/obstetric history
o Contraceptive use
o Hx of STI’s
o Previous pregnancies
o Pregnancy difficulties
o GTPAL
- Nutritional hx
o Based off response assess need for education
- Family history
- Current meds
o Including substance use and alcohol consumption
▪ Smoking
- Psychosocial hx
o Feelings of pregnancy
o Hx of depression
o Domestic violence history/risk
o Spousal/familial support
- Perform physical assessment
- Obtain bloodwork
o Hgb
o Hct
o WBC
o Blood type & Rh
▪ Rh blood test determines blood incompatibility of
 mother and fetus
o TORCH
▪ Screening for viruses that cross the placenta
▪ Toxoplasmosis
▪ Other infections
▪ Rubella
▪ Cytomegalovirus
▪ Herpes
o Urinalysis
o HIV antibody
▪ Can be transmitted via placenta and breastfeeding
o Syphilis
o Hep B
o Renal function tests
Ongoing Prenatal visits
- Normal visit schedule
o 16 – 28 weeks: monthly
o 29 – 36 weeks: every 2 weeks
o 37 till birth: once a week
- Monitor vitals
- Monitor for glucose, protein, and leukocytes in urine
- Monitor for edema
- Monitor fetal development
o FHR via ultrasound
o Measure fundal height
o From 18 – 30 weeks, fundal height = the weeks of
gestation
Education Throughout Pregnancy
- Educate on self-care/discomforts of pregnancy
- Educate on importance of prenatal visits
- Importance of loose clothing to promote circulation
- Encourage exercise
- Avoid:
 o All OTC meds unless told otherwise by provider
o Alcohol due to causing birth defects
o Smoking (tobacco) due to low fetal birth weight
o Consume 8 – 10 glasses of water a day
- Birthing options available to patient
o Doula
o Midwife
- Report complications
o Abnormal bleeding
o Contractions
o Abdominal cramping
- Safe sex
- Pain Management
o Aromatherapy
o Music therapy
o Acupuncture
o Yoga
o Guided imagery
- Monitor fetal movement
GTPAL
-
- G: Gravidity equals # of pregnancies
o Nullgravida: never been pregnant
o Primigravida: client in first pregnancy
o Multigravida: more than two pregnancies
- T: Term birth deliveries (38 weeks or more)
- P: Preterm births (37 weeks or less)
- A: Abortions/miscarriages (prior to 20 weeks)
- L: Living children

Alterations of Body Systems during Pregnancy

Reproductive
 - Uterus increases in size and changes shape/position.
- Ovulation and menses cease during pregnancy
Endocrine
- Placenta is endocrine organ that produces large amounts of
o hCg
o Progesterone
▪ Decreases contraction of uterus
▪ Prepares breasts for lactation, but inhibits
prolactin
▪ Increases resistance to insulin
• Coupled with poor diet, can cause gestational
diabetes
o Estrogen
▪ Inhibits milk production
▪ Triggers ovulation cycle
o Prostaglandins
- Relxain
o Increases joint laxity allowing flexibility of pelvis for
fetal passage
- Prolactin
o Stimulates lactogenesis
o Suckling of breasts stimulates prolactin to maintain
production
- Oxytocin
o Stimulates uterine contractions during birth and
postpartum contractions
▪ Uterine contractions push fetus down birth canal
▪ Postpartum contractions to shrink uterus and
control bleeding
o Stimulates milk ejection and is expelled into milk
Respiratory
- O needs increase for mother due to needing to supply for the
2

fetus
 - Size of chest enlarges to allow for lung expansion as uterus
pushes upwards
Cardiovascular
- Increased CO and blood volume causing cardiomegaly
- Increased HR
o Remains at peak level around 32 weeks of pregnancy
- Hypercoagulability due to increase in clotting factors
Musculoskeletal
- Calcium
o Intestinal absorption doubles due to increase of fetal
needs
o Enlargement of thyroid glands
- Postural changes
o Due to increase in relaxin and progesterone levels to
pass baby
▪ Widen stance of pelvis causing waddling
▪ Uterus increases in size during third trimester
• Causing the mother to lean back “lordosis”
▪ Stretching of abdominal muscles during third
trimester
• May causes diastasis recti which is
separation of abdominal muscles
GI
- n/v present especially in first trimester due to hormonal
changes and increase in abdominal pressure
o constipation
- often given a stool softener (Colace) during pregnancy
- formation of hemorrhoids if straining too often
Integumentary
- Often feel warmer due to increased metabolism
- Linea Negra
o Darker line located at midline of abdomen
- Varicosities noted due to dilation of veins
Vital sign changes
- BP
o Educate patient to lie on LT side to avoid hypotensive
syndrome and fetal hypoxia
▪ Fetal hypoxia occurs when mother is laying supine
causing compression of aorta, which in turn
blocks of oxygen supply to fetus

Nursing Interventions: Alterations of Body

- Acknowledge client’s concerns and encourage sharing of
feelings/thoughts
- Discuss expected physiological changes/discomforts and
possible timeline for return to the prepregnant state.
- Assist client with setting goals for postpartum period and
newborn care
- Encourage client to keep up with prenatal visits and report:
o Bleeding
o Contractions
o Leakage of fluid
-
Diagnostic Tests
- Nonstress Test (NST)
o Noninvasive procedure that monitors FHR and fetal
movement
- Biophysical profile
▪ Uses real-time US to visualize
physical/physiological characteristics of fetus via
stimuli.
▪ Combination of FHR (nonstress test) and fetal US
▪ Variables assessed include:
• FHR
• Fetal breathing movements
 • Body movements
• Fetal tone
• Qualitative amniotic fluid volume
- Contraction Stress Test
- Electronic Fetal Heart Rate Monitor (EFHRM)
- AFP
o Screening tool collecting blood sample to detect
neural tube defects
▪ If results are abnormal amniocentesis is performed
to confirm results
▪ High levels = possible neural tube defect
▪ Low level = possible down syndrome
- Chorionic Villi Sampling (CVS)
o Invasive procedure collecting chorionic villi from
placenta to diagnose any abnormalities
o Complications
▪ Spontaneous abortion
▪ Miscarriage
▪ Rupture of membranes
- Amniocentesis
o Invasive procedure obtaining amniotic fluid to assess
for chromosomal defects (down syndrome)
o Signed consent
o Risks to fetus
▪ Fetal hemorrhage
▪ Fetal death
▪ Preterm labor
▪ Leakage of amniotic fluid

Bleeding Complications
Spontaneous Abortions
- Pregnancy ends of natural causes prior to 20 weeks of
gestation
- Occurs in 1 trimester
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- Risk Factors
o Chromosomal abnormalities
o Advanced maternal Age
o Premature cervical dilation
o Maternal malnutrition
o Trauma
o Substance use
- Signs & Symptoms
o Abdominal cramping/pain
o Rupture of membranes
o Dilated cervix
o Hypotension
o Tachycardia
- Diagnostic Procedures
o Dilation and curettage (D&C)
▪ Scrape uterine walls to remove contents for
inevitable/incomplete abortions
▪ Signed consent required
- Nursing interventions
o Provide emotional support
o AVOID vaginal exams
o Educate:
▪ Notify provider of heavy, bright red bleeding
▪ Elevated temp
▪ Malodorous vaginal discharge
Ectopic Pregnancy
- Implantation of the ovum outside uterine cavity
o Usually implanted in fallopian tube which can lead to
a tubal rupture causing hemorrhage
- Occurs in 1 trimester
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- Risk Factors
o STI’s
o IVF
o Tubal surgery
o IUD
- Signs & Symptoms
o Unilateral stabbing pain/tenderness of lower abdomen
o Delayed menses
o Scant dark red/brown vaginal spotting 6 -8 weeks
after LNMP
▪ Red bleeding occurs in tubal rupture
o Referred shoulder pain
o Hypotension
o Tachycardia
o Pallor
o Dizziness
- Diagnostic Procedures
o Labs
▪ Progesterone and hCG to determine if it possible
ectopic pregnancy
o Transvaginal ultrasound
- Nursing Interventions
o Administer methotrexate as prescribed
▪ Kills/dissolves embryo by inhibiting cell division
o Administer IV fluids as prescribed
▪ Replenish fluid loss
o Salpingostomy
▪ Procedure to salvage fallopian tube if not ruptured
 o Salpingectomy
▪ Laparoscopic removal of fallopian tube if rupture
occurs
o Provide support
Placenta Previa
- Abnormal implantation of placenta near/over cervical os
(opening of cervix) instead of attaching to the fundus.
- Results in bleeding during 3 trimester causing dilation and
rd

effacement of cervix
- Three types
o Complete/total: cervical os completely covered by
placenta
o Incomplete/partial: placenta partially covers cervical
os
o Marginal: placenta is attached to lower uterine
segment but does NOT reach the cervical os.
- Risk Factors
o Previous placenta previa
o Uterine scaring via
▪ D&C
▪ C – section
▪ Endometritis
o Multifetal gestation
o Smoking
o Older than 35 y/o
- Signs and Symptoms
o Painless, bright red vaginal bleeding during 2 /3
nd rd

trimester
o Soft, relaxed nontender uterus
o Fundal height greater than usually expected
gestational age
o Vital signs WNL
- Diagnostics
 o Labs
▪ Hbg and hct to assess for blood loss
▪ CBC
▪ Blood type and Rh
▪ Khleihauer – Betke test
• Used to detect fetal blood in maternal blood
o Fetal monitoring
o Transabdominal/Transvaginal US for placental
placement
- Nursing Interventions
o Asses for:
▪ Bleeding
▪ Leakage
▪ Contractions
▪ Fundal height
o Do NOT perform vaginal exams
o Administer
▪ IV fluids
▪ Blood products
▪ Betamethasone
• Promotes fetal lung maturation if early
delivery is anticipated via c- section.
o Educate
▪ Bed rest
Abruptio Placentae
- Premature separation of placenta from uterus
- Two types
o Partial detachment
o Complete detachment
- Occurs 20 weeks after gestation ( usually in 3 trimester)
rd

- Commonly associated with disseminated intravascular

coagulation (DIC).
o Coagulation defect
 o Petechiae
• Evident for DIC
- Leading cause of maternal death
- Risk Factors
o Maternal hypertension
o Trauma
o Cocaine use
o Previous hx of abruptio placentae
o Nicotine use
o Premature rupture of membranes (PROM)
o Multifetal pregnancy
- Signs and symptoms
o Intense uterine pain with dark vaginal bleeding
o Board-like uterus/abdomen
o Hypotension
o Tachycardia
o Fetal distress
▪ Loses oxygen Placenta uterine insufficiency
• Causes fetal hypoxia
- Diagnostics
o Labs
▪ Hgb and hct to determine blood loss
▪ Khleihauer – Betke test
• Used to detect fetal blood in maternal blood
▪ Cross match/type blood
▪ PT/PTT
• Determine coagulation ability
o US
▪ Assess fetus
o Biophysical profile
- Nursing Interventions
o Palpate uterus for tenderness and tone
 o Measure fundal height
o Assess FHR
o Immediate birth is the management
o Administer:
▪ IV fluids
▪ Blood products
▪ Meds
▪ Oxygen
o Continuous fetal monitoring
o Provide emotional support
Gestational Trophoblastic Disease (GTD)
- Proliferation and degeneration of trophoblastic villi in the
placenta that becomes swollen takin on appearance of grape
like clusters and embryo is unable to develop.
- Two types:
o Complete mole
o Partial mole
- Risk Factors
o Hx of molar pregnancy
o Early teen/older than 40 y/o
- Signs and Symptoms
o Rapid uterine growth
o Dark brown/bright red scant or profuse bleeding
o Anemia due to blood loss
o Preeclampsia occurring prior to 24 weeks gestation
o No fetus found on US
- Diagnostics
o Labs
▪ hCG
o US
o DNC
o Rh negative patients receive Rho(D)
 - Education
o No pregnancy for a year

Medical Conditions

Hyperemesis Gravidarum
- Excessive n/v past 1 trimester causing:
st

o Electrolyte imbalance
o Dehydration
o Nutritional deficiencies
o Ketonuria
o Pre-term labor
o Underweight baby
- Risk Factors
o Maternal age younger than 30
o Multifetal gestation
o Gestational trophoblastic disease
o Stress
o Hyperthyroidism
o Diabetes
o GI disorders
o Family h/o hyperemesis
- Signs and Symptoms
o Excessive vomiting for prolonged periods
o Dry mucous membranes
o Poor skin turgor
o Weight loss
o Fatigue
o Dizziness
o Increased pulse rate
o Low BP
- Diagnostics
 o Urinalysis
▪ Ketones
▪ Acetone
▪ Elevated urine SG
o CMP
▪ Electrolytes
▪ Metabolic acidosis
• Due to starvation
▪ Metabolic alkalosis
• Due to hyperemesis
▪ Elevated liver enzymes
▪ Bilirubin level
o Thyroid test
o CBC
- Nursing Interventions
o Monitor I & O
o Assess skin turgor and mucous membranes
o Monitor vital signs
o Monitor weight
o NPO status until vomiting stops
o Administer
▪ IV for hydration
▪ Vitamin B and other vitamins
6

▪ Antiemetics
• Metoclopramide
• Ondansetron (Zofran)
o Appropriate diet as tolerated by patient
o Educate
▪ Eat small frequent meals
▪ Drink fluids in between meals
▪ Eat crackers/dry toast in the morning for n/v
▪ Drink plenty of fluids (as tolerated)
Gestational Diabetes Mellitus (GDM)
- Antagonist pregnancy hormones blocking insulin activity
causing insulin resistance
- Most women diagnosed with GDM during pregnancy
develop type II DM later in life.
- Risk Factor
o Obesity
o HTN
o Glycosuria
o Maternal age greater than 25
o Family h/o DM
o Previous delivery of a large baby or stillbirth birth
- Risk to fetus
o Macrosomia
▪ Large baby due to hyperglycemia
o Birth trauma
o Electrolyte imbalance
o Neonatal hypoglycemia
o Infection of mother due to increased glucose levels in
urine
o Hydramnios (too much amniotic fluid)
▪ Leads to:
• Distension
• Placental abruption
• Preterm labor
• PPH
o Ketoacidosis
- Signs and Symptoms
o Clammy pale skin
o Shallow RR
o Rapid pulse
o Vomiting
 o Excessive weight gain
- Diagnostics
o 1hr glucose test
▪ Performed in 2 trimester
nd

o 3hr glucose test

▪ Given if client fails 1hr glucose test
o Urinalysis
▪ Ketones to assess for ketoacidosis
o Biophysical profile
o NST
- Nursing Interventions
o Monitor blood glucose
o Monitor fetus
o Administer
▪ Metformin
▪ Insulin
o Education
▪ Perform daily kick counts
▪ Proper diet
▪ Exercise
▪ Self admin of insulin
Gestational Hypertension
- Begins after 20 weeks gestation
- Elevated BP on more than 2 occasions
o Systolic: 140 – 160
o Diastolic: 90 – 110
o BP tends to return to baseline by 12 weeks postpartum
- Four types of GH:
o Preeclampsia:
▪ GH with proteinuria ≥ +1
▪ Headaches
▪ Edema
 o Severe Preeclampsia
▪ Systolic: ≥160
▪ Diastolic: ≥110
▪ Proteinuria ≥ +3
▪ Oliguria
▪ Creatinine > 1.1
▪ Headache
▪ Blurred vision
▪ Hyperreflexia
▪ Peripheral edema
▪ Epigastric and RUQ pain
▪ Thrombocytopenia
o Eclampsia
▪ s/s of seizure or coma
▪ Preeclampsia s/s precede eclampsia
o HELLP Syndrome
▪ H: hemolysis – results in anemia and jaundice
▪ EL: elevated liver enzymes – elevated ALT and
AST causing epigastric pain and n/v
▪ LP: low platelets – less than 100,000 resulting in
thrombocytopenia, abnormal bleeding (gums,
petechiae, and possible DIC)
- Risk Factors
o Maternal age younger than 19 or older than 40
o First pregnancy
o Obesity
o Multifetal gestation
o Chronic renal disease
o Chronic HTN
o Family h/o preeclampsia
o DM
o Rheumatoid arthritis
o SLE
- Diagnostics
o Labs
▪ Liver enzymes
▪ Creatinine
▪ BUN
▪ Uric acid
▪ CBC
▪ Clotting studies
▪ CMP
▪ Urinalysis
o US to assess fetus
o NST
o Biophysical profile
- Nursing Intervention
o Assess LOC
o Monitor:
▪ Vitals
▪ I&O
▪ Daily weight
o Seizure precautions
o Administer
▪ Labetalol
▪ Nifedipine
▪ Hydralazine
▪ Methyldopa
▪ Magnesium sulfate
• Monitor: BP, pulse, RR, deep tendon
reflexes, urinary output, LOC
• Assess for toxicity
o Stop infusion
o Admin calcium gluconate
o Education
▪ Bed rest and in side-lying position
▪ Adequate fluid intake
▪ Report worsening sxs