Maternal-Child Nursing [4 ed.] 1437727751, 9781437727753

719 211 415MB

English Pages 1599 Year 2013

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Maternal-Child Nursing [4 ed.]
1437727751, 9781437727753

Table of contents :
2015-08-28 18_25_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_25_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_26_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_26_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_27_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_27_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_27_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_27_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_27_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_29_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_29_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_30_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_30_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_30_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_30_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_30_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_30_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_31_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_31_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_31_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_32_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_32_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_32_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_33_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_37_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_37_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_37_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_37_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_37_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_37_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_38_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_38_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_38_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_39_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_39_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_39_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_39_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_39_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_39_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_40_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_40_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_40_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_44_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_44_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_51_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_51_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_52_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_53_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_53_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_54_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_55_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_55_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_55_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_55_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_56_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_57_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_57_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_58_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_58_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_59_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_59_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_59_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 18_59_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 18_59_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_00_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_00_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_02_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_02_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_02_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_03_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_04_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_04_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_04_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_04_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_04_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_04_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_04_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_04_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_05_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_05_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_05_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_06_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_06_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_06_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_07_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_07_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_07_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_07_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_07_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_08_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_08_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_08_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_08_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_09_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_09_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_09_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_09_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_09_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_10_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_10_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_10_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_10_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_10_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_11_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_11_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_11_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_11_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_11_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_12_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_12_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_12_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_12_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_12_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_12_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_12_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
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2015-08-28 19_18_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_18_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_19_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_20_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_21_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_22_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_23_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_24_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_20-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_25-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_30-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_35-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_40-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_45-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_50-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_55-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_25_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_00-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_05-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_10-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_15-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_26_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_07-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_12-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_17-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_22-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_27-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_32-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_37-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_42-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_47-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_52-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_57-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_27_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_02-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_54-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_28_59-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_04-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_09-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_14-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_19-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_24-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_29-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_34-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_39-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_44-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_49-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_29_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_26-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_28-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_31-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_33-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_36-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_38-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_41-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_43-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_46-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_48-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_51-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_53-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_56-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_30_58-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_01-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_03-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_06-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_08-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_11-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_13-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_16-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_18-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_21-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_23-Tony's Kindle for PC 2 - Maternal-Child Nursing
2015-08-28 19_31_26-Tony's Kindle for PC 2 - Maternal-Child Nursing

Citation preview

•

urs1n~

FOURTH EDITION

MCKINNEY I JAMES I MURRAY I NELSON I ASHWILL

., •

http://ovotv . ISOViof.com

•

urs1n~

FOURTH EDITION

Emily Slone McKinney, MSN, RN, C

Kristine Ann Nelson, RN

Nurse Educator and Consultant Dallas. Texas

Assistant Professor of Nursing Tarrant County College Trinity River East Campus Center for Health Care Professions Fort Worth. Texas

Susan Rowen James, PhD, RN Professor of Nursing Cuny College MiIton. Massachusetts

Sharon Smith Murray, MSN, RN Professor Emerita. Health Professions Golden West College Huntington Beach, California

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Jean Weil£ Assistant Dean College of Nursing University of Texas at Arlington Arlington, Texas

ELSEVIER

3251 Riverpon Lane St. Lou is, Missouri 63043

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CHAPTER 9 TABLE 9- 1

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169

SEXUAL MATURITY RATING (SMR) : TANNER STAGES OF ADOLESCENT SEXUAL DEVELOPMENT- cont'd BREAST DEVELOPMENT IN GIRLS•

STAGE 1

Preadolescent

STAGE 2

Breast bud stage(thelarche): breaSt and papill a elevated as small mound. areolar diameter increased Early puberty. 9·13 yr

STAGE4

STAGE 3

Breast and areola enlarged. no contour separation

Areola and papilla form secondary mound

STAGES

Mature. nipple projects, areola part of general breaSt contour

Middle puberty: 12·13 yr Late puberty; 14 17 yr• PUBIC HAIR DEVELOPMENT IN GIRLS

STAGE 1

Preadolescent (none)

STAGE 2

Sparse, lightly pigmented, straight medial border of labia

STAGE3

Darker. coarser. beg1ming to curl . increased f!oler pubis

STAGE 4

Coarse. curly, less 10 amount than adult. typical female triangle

STAGES

Adult female triangle, adult quantity spread to medial surface of thighs

Early puberty: 10·11 Y.i yr Middle puberty: 11 Y.i·13 y1 Late puberty: 14Y.i· 1 6~ yr Modified from Tanner. J. M . (1962). Growth at adolescence(2nd ed.). Oxford: Blackwell Scientific Publications; Marshall, W . A ., & Tanner. J. (1969). Variations in pattern of pubenal changes in girls. Archives of Disease in Childhood. 44(235). 291 -303. Modified with permission from Blackwell Scientific Publications and the B MJ Publishing Group. •Breast and pubic hair development may continue into late adolescence and may increase w ith pregnancy.

deodorants become important to the adolescen t. With increasing hormonal activity, girls develop a more adu lt body con tour. As breasts mature, the nipples project more , and the pubic hair e.xtends to the medial thighs; the young female is estimated to be at Tanner stage 5. Ovulation may be established, and conception can occur.

Male Sexual Maturation The first sign of pubertal changes in boys is testicular enlargement in response to testosterone secret ion, which usually occurs in Tanner stage 2. Slight pubic hair is present, and the smooth skin texture of the scrotum is somewhat altered. As testosterone secretion increases, the penis, testes, and scrotum enlarge. The PHV

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usually occurs during Tanner stages 3 and 4, and the voice deepens and "cracks" as the cart ilage in the larynx enlarges. A.xillary hair develops, and the eccrine and apocrine sweat glands respond to stressful or emotional stimuli. Skin surface bacteria metabolii.e secretions from the apocrine glands, and body odor develops. Gynecomastia (male breast enlargement) occurs in approximately two thirds of young males during early adolescence and may be unilateral or bilateral (Ali & Donohoue, 2011 ). This phenomenon is olien disturbing to boys, and they need considerable reassurance that the breast tissue will decrease over time. During Tanner stages 4 and 5, rising levels of testosterone cause sebaceous glands lo enlarge, and excessive sebum may result in acne. The voice continues to deepen, facial hair appears at the corners of t11e upper lip and chin, and ejaculation may occur. Nurses need to provide anticipatory guidan ce to adolescent boys regarding involuntary nocturnal emissio ns of seminal fluid ("wet dreams") and assure them that th is occu rrence is normal. By Tanner stage 5, genital maturation is co mplete, spermatogenesis is well established, facial hair is present on the sides of the face, and the male physiqu e is adultlike in appea rance. Gynecomastia significantly decreases or disappears, much to the adolescent male's relief.

Motor Development Adolescents often engage in various fo rms of motor activity, from aerobic exercise to football. Mo tor activities such as sports and dancing provide an outlet for the adolescent's energy, as well as an opportunity for competition, teamwork, and social relationships. Large muscle mass increases in adolescents, and coordination of gross and fine muscle groups improves. \'Vitll practice, adolescents become more adept at atlllerics and also at art, music, sewing. and other activities that require fine motor skills. The bones are not completely calcified until after puberty and are still fairly resistant to breaking in the young adolescent. Participants in sports activities should be grouped according to tlleir size and their sexual maturity racing rather tllan tlleir cluonologic age. A small, thin, late-maturing boy is less capable of competing with an early maturing, muscular classmate, and injuries are more likely to occur if they are grouped toge tiler. Nurses, particularly school nurses, may be helpful in assessing adolescents' growth and development and cow1seling them about sports activities in which they can succeed ratller tllan those in which they will meet with physical and psychological failure. Adolescents should have a yearly ph)rsical exam ination if participating in high school athletics ( Box 9- 1); the school nurse keeps docum entatio n of th is matter. Beca use it is gen erally superficial, the school sports exam ination sho uld not subst itute fo r the reco mmended co mplete adolescent physical exam ination wit11 cou nseling.

D SAFETY ALERT The Adolescent Who Is Involved in Athletics Adolescents participating in athletics need the following: • Adequate equipment • Appropriate training schedules ., Frequent rest penods _ • Adequate fluids to_prevent injury; deh~rat1on. aoo exhaustfon

BOX 9 -1

• • • • • •

NURSING GOALS FOR PREPARTICIPATION SPORTS PHYSICAL EXAMINATION

Assess the adolescent athlete's general health. ldentifycondittons tratcould limit participation or predispose toinjuiy. Assess the adolescent athlete's physical and psychosocial maturity. Determine the athlete's fitness relative to performance requuements. Assess legal insurance requirements for partic1pa1ton. Provide wellness colllsefing and an11c1patoiy guidance.

The development of the cardiovascular pump plays an essential role in t11e adolescent's participation in gross motor activities. Cardiopulmonary capacity increases during adolescence and is relatively mature in the late adolescent. The cardiovascular pump is not as efficient in young adolescents, whose lungs are smaller. Adolescents generall)' cannot run as fast or as long as )'Oung adults. The athlete's aerob ic power, body composition, joint flexibility, an d strength of skeletal muscles determine physical fitness.

Cognitive Development Cogn itive development in nuences every aspect of adolescent psychosocial development. Cogni tion moves from concrete to abstract tllinking during the three phases ofadolescent development. According to Piaget ( 1969), formal operations, or abstract thinking, characterize the last stage of cogn itive development. Early abstract thinking encompasses inductive and deductive reasoning, the ability to connect separa te events, and the ability to understand later consequences. Abstract thinking in late adolescence is increasingly logical, and young adults are capable of using scientific reaso11ing, understanding complex concepts, and using analytic methods. Because of logical reasoning, adolescents are able to differentiate between others' perceptions and tlleir own and to view social situations from a societal perspective. In a review of adolescent cognitive development, Cromer ( 2011 ) states tllat t11e brain is still maturing during adolescence, and tllis maturational process affects cognitive and emotional processing. Increased myelinization of neurons, along with maturation of the superior temporal gy rus and the prefrontal cortex facil itate impulse control, decision-making skills, ability to unde.r sta nd consequences of alternative actions a nd prioritization. Th is aUows for increased o rga nization and problemsolving skills, as well as cr itical th inking. C ro mer (2 0 11 ) also states that poss ible hormonal influences heigh ten emotional se nsitivity and intensity, which affects adolescent stress and risk-taki ng behavior. The implica tions of this fi nd ing for nurses a re especially apparent for health teach in g. Adolescents tllink in different ways tllan adults. For example, sex education for nintll graders is quite different from that for college freshmen or adolescents with tlleir first full-time jobs. The college freshman should be able to appreciate tile later consequences of sexual behavior, whereas the young adolescent is focused on tile here and now. For example, one should ask tile nintll grader and tile college freshman how an unwanted baby will affect their lives, and compare their answers.

CHAPTER 9 For a var iety of reasons (includ ing, for example, poor comprehension ability, lack of education, and chronic substance abuse), some older adolescents remain concrete thinkers. Nurses and educators need to know the ir audiences and address them appropriately. Nurses may need to help parents learn how to communicate with their teens appropriately. Counseling a group of adolescent substance abusers may be ineffective if the consequence of their behavior is tied to the future when their thinking is in the present. A professional approach to communicating with teens includes the following: Enjoy them. Be patient and flexible. Know adolescent development; consider how a teen will look to peers. Be open to their ideas and opinions and willing to negotiate choices. Listen nonjudgmentally, keep ing criticism to a minimum. Encourage problem solv ing and mutual decision making. Ma in tain confide ntial ity. Be an advocate, bu t do no t take sides against a parent. Explore feel ings abou t hea lth ca re cho ices, an d allow for questio ns a nd a nalysis of health care op tio ns.

Sensory Development Adolescents' eyes and ears are full y developed, an d with the exception of refractive errors and occasional minor infections of the eyes, ears, and sinuses, the sensory system remains qu ite healthy. Myopia occurs in ea.rly adolescence, between ages 11 and 13 years, often requiring frequent changes in corrective lenses. Because of increased participation in competitive sports and outdoor activities, eye injuries are common in adolescence. Boys are more prone to eye injuries i:han are gi.rls. Adolescents should always be required to wear safety or protective equipment when competing in sports or participating in any activity that may compromise eye safety.

Language Development 'With the acquisition of formal operational thought and adequate intellectual capacity, adolescents are able to understand abstract concepts, process complex thoughts, and e.xpress themselves verbally. Adolescents who read extensively are generally more art iculate and have a la rger vocabula ry than those who do n o t. Social developmen t a nd self-co nfidence play a significant role in how well adolescents exp ress th emselves verbally to others. Shy, in troverted adolescents may have d iffic ulty speaking to a group or members of the opposite sex but may w rite expressively. Conversely, ext roverted, social adolescents who have n o trouble with verbal expressio n may lack the reading a nd writing skills for effective written commun ication. Computer technology has added to the adolescent's aven ues for creative expression. Adolescents are capable of expressing ideas in symbols and abstract concepts, and many enjoy interpreting or even developing complex computer programs. Computers have a symbolic language of their own that some adolescents find fascinating. Teens may become more proficient with computer technology than their parents. In addition

Health Promotion for the Adol escent

171

to teaching teens basic computer li teracy, many h igh schools have computer dubs where students who excel in computer languages share ideas and knowledge of computer information systems. Because of safety concerns with young adolescents using the Internet, parents need to monitor computer use and investigate whether parental controls available through some Internet access companies are appropriate for their child. Electronic or digital vehicles for communication have impacted language communication as well. Social media websites, e- mail, telephone text messaging, instant messaging, biogs, and Twitter all contribute to abbreviated communication techniques, whid1 eliminate not only grammar and sentence construction, but also word construction (e.g., using ur, for you are). Communicating with adolescents sometimes presents a challenge to parents and other adults. Although adolescents are capable of verbal expression, they are also intensely private and may not wish to divulge their thoughts a nd feelings to others. Developmentally, the verbally exp ressive 12-year-old may turn into a relatively uncommu ni cat ive 14-yea r-old. Co nflict w ith parents in creases tensio n in co mm u ni cat io n (see Pare nts \.Vant to Know box: Commu n icating with Adolescents).

PARENTS WANT TO KNOW Communicating with Adolescents Parents need encouragement to maintain open communication with their teenager while not appearing too intrusive. Inundating adolescents with questions or going through their belongings causes feelings of invasion and a lack of trust. Adolescents gel more out of discussions in which they participate than they do out of lectures and are more likely to respond positively to adults woo listen and appear interested in wN!t they have to say. Nurses who work with adolescents must develop communicatbn sldls that include assuring confidentiality, making no assumptions, remaining non)Jdgmental, and pOSing open-ended questions. Questions such as "Tel me about your plans for the future" wil glean more information than "Do you plan to go to oollege?" The queslbn "Do you live w~h your parents?" makes an assumption about the living situation that could make the adolescent feel uncomfortable. "Describe where you live and who lives with you" gives the adolescent an opportunity to discuss the living situation.

Psychosocial Development ldentity forma tion is the major develop mental task o f adolescen ce; other tasks in clude the fo rmatio n of a sexual a nd voca tional identi ty an d the ability to ema ncipa te o neself from the family or become independen t (Figure 9- 1). Ene rgy is focused within the self, and the adolescent is desc ribed as egoce ntric o r self-absorbed. Frustrated parents o~en descr ibe teenagers during this phase as self-centered, lazy, or irresponsible. In fac t, they just need time to think, concentrate on themselves, and determine who they are going to be. E ri k~on ( 1968) described the conflict of this phase of psychosocial development as identity formation versus role confusion; this phase corresponds to Freud's genital stage of psychosexual development (see Chapter 5 for information on developmental theories ).

172

CHAPTER 9

Health Promotion for the Adolescent

Relationships with the opposi te sex are more mature by late adolescence. Late adolescents have more realistic expectations of both themselves and those who are important to them. They devote many hours and much anxious thought to making events. such as prom night, memorable for a lifetime. Some adolescents may be left out because they are unpopular or shy or do not have the financial resources to participate in these special events.

With the freedom driving brings to the adolescent, comes responsibility. The adolescent's inexperience and risk-taking behaviors can be a lethal combination.

Computers in school and in many homes provide the ado- Although teens often have lescent with opportunities for learning, creative expression. friends of both sexes. they are communication. and entertainment. Adolescents often more comfortable sharing their enjoy "surfing" the Internet, which can provide them with hopes, dreams, secrets. and information not readily avail abl e locally. Parents must moni- even embarrassing incidents tor their adolescent's computer connections, however, for with friends of the same sex. these networks sometimes allow access to people and activities that conflict with family values. FIG 9-1 Adolescent growth and development.

In the transitio n per iod from ch ildhood to adulthood, ado lescents try new roles and expe riment with the environment

until they find a role that fits. The phase of experimen tatio n has been termed the moratorium, meaning a period of delay gran ted to someone not yet ready to make more than a tentative commitment (Erikson, 1968). The adolescent's changing interests from year to year illustrate the lack of commitment. Parents may invest in expensive sports equipment or a musical instrument only to find it abandoned after a short time.

The peer group plays an essential role in adolescen t identity formation. Teenagers take their cues o n appearance, social behavior, and la nguage from the peer gro up. The peer group serves as a safe haven as adolescents emo tio nally move away from the family and struggle to determine who they are. The peer group valida tes acceptable behavior, and teenagers feel secure in trying on new roles with peer-group approval. Teens frequently spend al l day with friends in school and all evening rehashing the day's events over the phone or through postings

-

CHAPTER 9 BOX 9-2

AGE-RELATED ACTIVITIES AND GAMES FOR ADOLESCENTS

General Activities Games ard athletics are the most common forms of play. Strict rules are in place. Competition 1s important Games and Special Types of Play SpoJts. ~deos. m111ies. reading, panies, Mbbies. listening to favorite music. experimenting with makeup ard hairsl'jles, talking on the telepMne or cell pMne. playing computer games. panicipatong in social media disco1.1se.

on social media websites ( Box 9-2). Changes in the adolescent's body image, psychosocial development, and peer group acceptance are closely related. Early and middle adolescents are particularly audience co nscious and feel that they are the focus of everyone's attention. A bad hair day o r a blemish may throw the adolescent into despair. Clothing, hai rst}~es, and material possessions that are accepted by the group become the most important. Nurses cou nsel pare nts to nego tiate cho ices with teens but always consider how peers will judge the ch ild.

D

NURSING QUALITY ALERT

The Adolescent and Erikson • Identity formation ard establishment of autonomy • Acquisition of abstract reasoning leading to the following: • Analytic thinking • Problem solving • Plaming for the future Early adolescence and middle adolescence a.re the periods when teens are prone to gang formation a nd activities. Peer modeling and peer acceptance, being of the utmost importance, lead some adolescents to form gan~ that provide a collective identity and give them a sense of belonging. Peer pressure, companionship, and protecLion are the most frequently reported reasons for joining gangs, particularly those associated with violent or criminal acts. Early and late adolescence have marked developmental differences. Each age-group ha s unique reactions to the developmental tasks, whi ch are inOuenced by the adolescent's cognitive thinking. Accord ing to Piaget ( 1969), adolescent cognition is characterized by the transition rrom co ncrete operational thought to formal operat io nal tho ugh t, the ab ility to think logically and use dedu cLive a nd abstract reaso ning ( in addition to tl1is chap ter, see Chapters 5 through 8) . The acquisition of formal operational thinking allows the adolescent to recall past experience and to apply knowledge to the future by drawing logical consequences fro m a se t of observations. Adolescents are capable of using abstract symbols suc h as those derived from higher -order mathematics, making and tes ting hypotheses, and considering and argui ng philosophic issues. Problem-solving and decision-making ski lls become more highly developed, although adolescents may still be conflicted about idealism versus reality.

Health Promotion for the Adolescent

173

Early Adolescence The early adolescent ( I I to 14 years) has intense feelings about body image and the many physical changes taking place. Less confident with members of the opposite sex, early adolescents tend to group together and have best friends of the same sex. One has only to visit the local mall or a movie theater to see groups of young teens of the same sex, observing but rarely speaking to groups of the opposite sex. The early adolescent is quite egocenLric and may move from obedience to rebellion regarding parental authority. Parents are often shocked by the sudden turn of events and are hurt by the teen's rejection. Providing parent~ with a nticipatory guidance regarding age-specific developmental changes is a primary nursing function. For example, the happy-go-lucky 11-)'ear-old may turn into the shy, self-absorbed 12-year-old who seems comfortabl e o nly in Lhc presence of friends. Young teens, who are developmenlally egocentri c, fail to differentiate be.tween how others see the m a nd their own mental preoccupations, thinking ever)'O ne is as obsessed with them as they are witl1 themselves. Elk ind ( 1993) describes th is phenomenon as a reaction to the imagiliar)' aud ience. The belief in the imaginary audience is probably why you ng teens are so self-co nscious; they believe everyo ne is critica l of them, and indeed teens are quite critical of one another, espec ially those who are different. Self-conscious behavior may also be the result of the physical and emotional transitio n to middle adolescence. The early adolescent is losing the fami liar role of the child but does not ye t feel comfortable with the role of the adult. Ambivalence toward independence is common, and the teen who feels too grown up for a good-night kiss from a parent sti ll falls asleep with a favorite teddy bear. Elkind (1 993) believes that because young teens a re so audience conscious, tl1ey see themselves as unique and tell themselvesa "personal fable" that supporLS feelings ofinvulnerability. They believe bad tilings will happen to otl1ers but not to them. Adolescent suicide attempts, for example, serve as a dramatic message to others, but young teens often do not realize the final consequences of their actions.

Middle Adolescence Middle adolescence ( IS to 17 years) is often described by parents as the most frustrating period o f adolescent development. The real audience gradually repla ces the imaginary audience, and teens become even more introspective and narcissisti c. Co nformity to peer-group norms beco mes even more important, and conflicts between teenage rs and parents often escalate. Testing of limits, sulky withdrawal, a nd ove rt rebellion may occur over conflicts regard ing curfews, friends, activities, appearance, cars, and money. The adolesce nt may feel mo re secure by associating with or becoming a member ofa gang ( Box 9-3) . Nurses counsel parents to nego tiate c ho ices when possible and set limits that are perceived as reaso nable by the adolescent. Consistent disci pline and structure actually make adolescents feel more secure and assist them with decision making. With parental guidance, adolescents are able to make decisions that will result in desirable outcomes. Adults must keep in mind that middle adolescents are impulsive and impatient, however. Parental concern

174 BOX 9 -3

CHAPTER 9

Health Promotion for the Adolescent

SIGNS OF GANG INVOLVEMENT

• Associating with new friends while ignoring old friends. The adolescent usually will not talk about the new friends or what they do together. • A change in hairstyle or dO!hing and associating with O!her youths with the sarre style. Usually sorre ol the clothing. soch as a hat or 1acket. has the gang's colors. initials. or "street" name on it. Parents may note tanoos on the boctf. • Unexplained source ol 111lney OI ?)SSess1ons (e.g .. stereos. jewelry. cars). • Indications of lems at school. in ptblic. or at home. Youth no longer accepts parents' authority and challenges 11 frequently. • Problems at school. sud1 as failing classes. skipping school. and causing problems in class. • Fear of the police. • Unexplained signs of fighting. such as bruises. cuts. and reports of pain. • Graffiti on or around residence or possessions. • Threats from rival gang members. Sometimesa lamily member is a victim of a drive-by shooting before the family reali zes the youth is involved in a gang.

may be seen as interfe rence rather tha n gu idance and may be met with resistance and resen tment. Feelings about self-image and soc ial relationships are intense. Middle adolescence is ge nerally a time of transition from same-sex friendships to an extreme inte rest in the opposi te sex; it is also a time whe n adolescents may acknowledge homosexual feelings. The proportion of teens who are sexually experienced and sexua lly active has declined slightly, as has the teen birth rnte (Centers for Disease Control and Prevention [CDCJ, 20 l la,b ). Nurses and other health care providers cannot become complacent in response to this change in trends. The United States still has one of the highest adolescent birth rates compared to other developed countries (CDC. 2011 a). In a recent survey by the CDC (2010), 5.9% of adolescents reported initiating sexual intercourse before age 13 years, and 46% of the ninth through twelfth graders surveyed had had sexua.1 intercourse at least once. Of concern is the trend for early initiation of sexual intercourse. Sexual activity is often related to peer pressu re and selfesteem issues. Adolescents with low self-esteem are more vulnerable and are mo re apt to engage in negative risk- taking activities associated with sexuality. Decisions about sexual activity are often impuls ive a nd made with little regard to later conseque nces or prior prepa rat io n. In fact, according to the 2009 Youth Risk Behavi o r Su rveilla nce Survey (YRBSS) (C DC, 2010), of the teenagers who repo rted bein g currently sexually active, 39.9% reported they d id not use a co ndom at last intercourse. Anotl1er co ncerning trend amo ng adolescents is the increasing participation in o ral sex. Recent repo rts of nation al statistics suggest that tlie prevalence of oral sex among adolescents 15 to 19 years o ld exceeds 50% (Li ndbe rg, Jones, & Sa ntelli, 2008). Questions about ora l sexua l activity are not currently included in the YRBSS. Halpern -Fels her (2008) states that adolescents intend to have oral sex for a variety of reasons, but primarily because they believe it is more socially acceptable than vaginal

interco urse and does no t ca rry the same risks. This and other evidence-based informat io n (CDC, 2009; Lindbe rg et a l., 2008) suggest that, although many ado lescents may know that human immunodeficiency virus (HIV) and otlier infectious diseases can be contracted from engaging in oral sex, they, nevertheless, do not consider oral sex to be as risky as vagina l sex. Nurses and other health professionals who assess adolescent health status need to be more specific when interviewingadoles· cents about sexual activity. l11e question of whether an adolescent is sexually active is no longer sufficient; questions should be directed toward assessing participation in various specific types of sexual activity as well as the method of barri er protection used. Nurses may help by providing accurate information to assist adolescents in making appropriate sexual choices. Parents need encouragement to maintain open commun ication and guide teenagers in sexual decision making. Providing parental guidance about sexual behavior is not easy du rin g middle adolescence, when privacy is o f extre me impo rtance and commun ication with parents tends to decrease. In add iti o n, some parents may find sexual behavior a d iffi cult top ic to discuss and often avoid talking with teens about sexual issues altogether.

D

NURSING QUALITY ALERT

Elements of Adolescent Care Nurses working with middle adolescents need 10: • Be approachabl e • Maintain objectivity • Encourage confidence • Sup?)rt parental authority • Be a child advocate while not coming between adolescents and their parents • Encourage the family to work as a rrutually respectful unit

Vocational Exploration. In the initial stages of establishing a vocational identity, adolescents are more likely to experience role confusion and have unrealistic expectations of themselves. Some adolescents identify a role that holds their interest, whereas others experiment with many roles, moving quickly from one role to another. Overidentification with glamorous roles takes precedence over reality and is enriched by da)'dreams and fantasy. A JS -)1ear-old girl may spend time witl1 her friends describing her future as a popular med ia sta r while failing to fold the laundry or do the dishes. During middle adolescence, so me teens acqu ire part-time jobs and identify vario L1s ski lls and interests. Part-tim e jobs are often a source of in come for material possessio ns and activities not provided by pare nts. Such experiences help adolesce nts set real istic expectations about work, become more independent, and develop self-esteem. Those who a re successful in the wo rking world demonstrate a se nse of responsibili ty a nd tend to have more positive soc ial interactio ns. I lowever, some adolescents may allow work to interfere with educatio na l activity and have difficulty setting priorities. School nurses, in collaborntion with parents and teachers, are in an excellent position to identify working students and assist them in sening realistic guidelines for work and education.

CHAPTER 9

Late Adolescence (18 to 21 Years) Late adolescence is characterized by theabilityto think abstractly, conceptualize verbally, and express thoughts and feelings about various aspects of life. Late adolescents tend to be idealistic about love, social issues, ethics, and li festyles until their experiences modify their beliefs. Conformity becomes less important as teens progress through late adolescence. \'Vith the development of a unique identity, self-esteem increases, and adolescents are able to resist group pressure if it is not in their best interest. Interactions with parents are less turbulent unless values clash, and relationships with both friends and family are maintained. Emancipation (leaving home) is a major issue; late adolescents prepare themselves to meet this task through education or vocational training. Identifying realistic career goals is important, but many adolescents are not yet ready to make lifelong commitments. Cha nging ca reer goals is not wKommon, but the nurse should watch for those adolescents who have set no career goals, who demonstrate apathy about the future, and who appear committed only to the p resent. Boredom and apathy are often S)'ll1ptoms of o greater problem: depression. Social relationsh ips a re mo re matu re, although partner selection often conti nues to fluctuate. Friendsh ips developed in late adolescence may last a lifetime, and expectations of friends and loved ones become more realistic and less self-serving. The ability to consider others' needs increases, and recognition of societal needs is more apparent as the adolescent moves from adolescence to ad ult hood. Failure to achieve identity formatio n may leave adolescents in role confusion and inlpede the successful mastery of the tasks of young adu lthood. A positive ego identity depends on the adolescent 's ability to accept the past, learn from experience, and become engaged in the future. Most adolescents move through the identity versus role confusion stage of development with minimal difficulty.

Moral and Spiritual Development Children develop moral reasoning in a sequential manner, as described by American psychologist Lawrence Kohlberg ( 1964}. As adolescents move from con crete to analytic thinking, they advance to Kohlberg's stage 4 conventional level or Kohlberg's stage 5 postconventional level of moral development. Adolescents who remain co nc rete thinkers ma)' never advance beyond Kohlberg's stage 3 of moral reason in g: conformity to please others mid avoid pun ish ment. The teenager's sense of justice is developed through interpersonal relatio nships with peers, fam ily, and other adult role models. Behaviors that a re modeled and rewarded, such as help ing the less fo rtunate and showing loyalty to friends, contribute to the development of a conscience, which operates as a moral guide for subsequent behavio r. The middle to late teenager can appreciate that stealing from others is wrong regardless of whether one is caught and punished. Adolescents and young adults develop a respect for law and order and a society-maintaining orientation ( Kohlberg's stage 4). Young adults may even advance to the societal-perspective stage (Kohlberg's stage 5). which honors the moral rules of right and wrong, contractual agreements, majority opinion, and overall utility or the greatest good for the greatest number (see Chapter 5).

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Older adolescents and yo ung adults question the values of family and society and cha llenge existing moral codes before integrating their experiences and beliefs into a personal moral framework. Once the moral framework is developed, interpersonal relationships tend 10 be with those whose va lues and beliefs are similar. Young adolescents in the stage of concrete operational thought are able to think logically. In this stage, cliildren deal well with the observable but also begin to see other points of view and examine what they have learned. lbe young adolescent will accept religious teaching and examine how religious concepts relate to everyday life. Young adolescents are especially inclined to look to God for guidance when troubled. Middle to late adolescents are capable of analytic thought and may begin to question the religious affiliation of the family, much as they question other family values. Older adolescents may explore different kinds of religion and sha re religious activities wid1 the peer group. Evidence suggests that sp irituality has a positive effect on heald1- related qual it)' of life in adolescents (Cotto n, Tsevat, & Yi, 2007). Spiritual ity ma)' also be protective fo r both physical and emotional well -being ( Rub in, Dodd, Desai, et al., 2009). As part of providing holistic nursing care, nu rses need to include an assessment of spiritual bel iefs and values when wo rking with adolescents and in co rporate these values in nursing in terve n ti o us.

HEALTH PROMOTION FOR THE ADOLESCENT AND FAMILY Adolescence is generally a period of wellness. Young people may seek health care for school or sports physicals, skin conditions (acne, contact dermatitis). acute minor illnesses (colds, flu). conditions related to sexuality (birth control, pregnancy, sexually transmitted diseases [STDsl}, and the management of chronic illness (diabetes, epilepsy). I lealth promotion and disease prevention are achieved through adequate nutrition, rest, balanced exercise, and proper immunization against disease. During well visits for health promotion, adolescents confer privately with die nurse and tl1e health provider; separately, parents are asked about any co ncerns tl1ey might have. Confidentiality is often an issue when adolescents are seen in the health care setting. Nurses should enco urage adolescents to involve their parents, but adolescents frequent!)' ask d1at communication be kept confidential. The adolescent must understand that the nurse will respect th is confidential ity unless the in formation shared suggests a potentially life- th reaten ing danger either to the adolescent or to others.

(?)

CRITICAL THINKING EXERCISE 9-1

The nurse is caring for a1f>.year·old girl. Heidt. who has been admitted to the hospital with deh~ration. She is quiet and answers questions with a simple ·yes· or On the day Heidi is to be discharged. she says. ·ru tell you something. but you can't tell arryone else." 1. What factors rrust the nurse consider in this situation? 2. What would be the nurse's best response?

·no:

176

CHAPTER 9

Health Promotion for the Adolescent

Adolescents need to be directly asked questions about their health. These include questio ns about d iet and exercise, sexual risk behavior, substance use, preventive safety measures (e.g., seat belt, bicycle helmet, protective sports equipment), violence, peer and fan1ily relationships, and emotional health (AAP Committee on Adolescence, 2008 ). Screening tools are available that perform an adolescent assessment in an organized manner. Guidelines for Adolescent Preventive Services (GAPS) is an assessment program that looks at parenting, development, drugs, sex, learning problems, depression, abuse, safety, and diet and fitness. GAPS is a comprehensive packet of services that includes screening and preventive services {American Medical Association, 1997). 11lere are specific screening tools that assess for emotional and mental health issues. One of these is the Diagnostic Predictive Scales-8 (DPS-8), which is a questionnaire about mental health issues including su icide (ideation, attempts), phobias, general anxiety, substance use, and depressive symptoms {Husky, Miller, McGuire, et al., 2011 ). Questionnaires ca n be adm inistered befo re the adolescent comes to the provider or in th e provider's o rfi ce, eith er by paper and pencil or by computer ( Husky et al., 20 I I). So me providers pub! ically display their poli cy o n co nfide ntiality, always underlin ing the need to share info rmatio n o nly if someo ne is in danger. Issues related to the time necessa ry for an adequate interview may arise in the current managed care e nviro nment. Nurses should be knowledgeable about co mmunicating with adolescen ts and aware of when referral is warranted. Access to regular quality health ca re for adolescen ts has become an increasing issue of concern because of its importance to the prevention of illness related to adolescent risk behavior (AAP Commiuee on Adolescence, 2008 ). Regular health promotion visits to a provider during adolescence facilitates comprehensive health screening, preventive intervention, counseling, and referral. Many adolescents and their parents perceive the yearly sports physical as being sufficient. However, this physical, often performed by a school physician, is not comprehensive enough to identify subtle problems, nor is it likely to provide time for confidential communication of adolescent concerns to the provider ( AAP Committee on Adolescen ce, 2008). For this reason the AAP Committee on Adolescence (2008) recommends tlrnt access to comprehensive health care for adolescents be widely available in a variety of venues that include school-based health cl inics, physicians' offices, community or public health cl in ics, and hosp ital s. In addit ion, the Comm ittee reco mm ends o ffering assurance of confidential ity, comprehensive serv ices, ca re that is culturally and ethn ically relevant, and health insurance coverage for all adolescents (AAP Committee o n Adolescence, 2008).

Nutrition during Adolescence The accelerated growth (in linea r heigh t, weight, and muscle mass) and sexual maluration during adolescence increase teenagers' nutritional needs, including needs for protein, calories, zinc, calcium, and iron. Periods of intense growth require increased caloric intake, and the adolescent appears constantly hungry. Snacks and regular meals need to contain adequate nutrients to meet the body's anabolic needs. Adolescents are

BOX 9 -4

FACTORS INFLUENCING THE ADOLESCENT'S DIET

• Busy schedule (sports. activities. jobs) • Body image concerns. which can lead to undereating

• • • •

Skipping breakfast Eating ;m~ from home Eating fast food frequently Begiming to oov and prepare own food • Peei pressure • Psychological and emotional prot:Aems

generally interested in nutrition and the effect food has on their bodies. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. These issues, together with the adolescent's growing independence, can have nutritional impl ications.

Age-Related Nutritional Challenges The adolescent's food hab its a re influenced by many factors (Box 9 -4). Unfortunately, th is happe ns at a time when the body has greater nutritio nal needs. Boys tend to have fewer nutritio nal deficiencies than girls because they take in more food and are less likely to be dieting. Soft dr in ks freq ue ntly replace milk. Fast foods and low- nutrient "junk foods" sometimes become the mainstay of the adolescent 's d ie t. The soc ial a~pect of food consumption gains importance, and adolescents may p refer to eat meals with peers at social gatherings and restaurants of their choice. Parental supervision of mea ls declines as the adolescent spends more time away from home and engages in ext racurricular activities with peers.

Nutritional Guidance for the Adolescent The nurse needs to understand growth and development to be successful in cowlseling adolescents and their parents about nutrition. Adolescents' increasing need to be independent and make their own d1oicesshouldguide the nurse in teaching nutrition. The adolescent should always be involved in the planning. The nurse should assess the adolescent's present diet and determine habits and eating patterns. The assessment should elicit how often the adolescent eats food from the differen t food groups and what foods the adolescent does not eat. On the basis of tllis information, nutritious foods for meals ca n be identified and a plan developed. In general, the U.S. Department of Agriculture {USDA) (2011) recom mends 1600 to 1800 calo ries per day for adolescent girls and 1800 to 2200 ca lories/day for adolescen t boys, with foods coming from a variety of groups-whole grains, fruits and vegetables, dairy, and protein (plant and animal). Adolesce nts should drink at least three cu ps of milk a day and limit fats to 25% to 35% of total daily calo ries co nsumed. Adolescents need calcium and vitamin D to prevent future osteopo rosis, and adolescent girls require adequate iron and folic acid ( 400 mcgl day from supplements or folic acid-fo rtified foods) (USDA, 20 11). Recently, the use of so-called energy drinks has increased in the adolescent population. These drinks contain large amounts of caffeine, along ,.;jth glucose and other, non-regulated, substances. The AAP Committee on Nutrition and the Council on

CHAPTER 9

Health Promotion for the Adolescent

177

prevalent during the adolesce nt years: gingivitis, malocclusion, and dental trauma. Gingivitis is the inflammation and breakdown of the gingival epitlieli um; the gums appear pale and swollen and bleed easi ly. Increased hormonal activity at the time of puberty, diets nigh in sugar and simple carbohydrates, and the use of dental braces and appliances that make cleaning less effective are thought to contribute to the development of gingivitis.

Sports Medicine and Fitness (20 11 ) have stated that energy drinks are inappropriate fo r children and adolescents because they can contribute to obesity as well as other health problems related to calfeine ingestion and excessive glucose. The nurse can a lso assist the adolescent by pointing out nutritious fast foods and snacks. An awareness of nutritious fast foods can also aid the adolescent in meal selection. Many fast-food chains have salads with nonfat or low-fat dressings, grilled chicken sandwiches, pasta, and nonfat yogurt. Fat and salt contents have been reduced, and vegetable fats have replaced animal fats at some restaurants. Adolescents should be guided to mix an occasional hamburger and fries with a regular selection of more nutritious foods. Permission should be given to eat foods that may be untraditional at a particular meal, such as pizza for breakfast. Many adolescents decide to follow a vegetarian diet during their teen years. Several dietary organizations have suggested that a vegetarian diet, if correctly followed, is health)' for this population because the low-fat aspect of the diet can prevent future card iovascular problems (Stettle r, Bhatia, Parish, et al., 2011). If an adolesce nt wish es to follow a vegetarian diet, the nurse can assist with phmn ing food choices that will provide sufficient calo ries and necessary nutrients. The focus is on obtaining sufficie nt calo ri es for growth and energy through a variety of fruits a nd vegetables, whole grains, nuts, legumes, seeds, tofu, and soy milk; so me vegeta rians choose to eat eggs and dairy products as well (S tet tler et a l., 2011 ). As with any adolescent, nurses need to advise adolescents who follow a vegetarian eating plan to avoid low- nutrient, high -fa t foods. Body image is of particular importance to adolescents. The media reinforce the belief that " thin is in." Adolescents hold themselves to standards set by the entertainment and advertising worlds, which emphasize fitness, glamour, and se.'.=~~~

23 chromosomes (22 au10somes and 1 X chromosome)

Secondary oocyte containing 23 chromosomes (22 autosomes and 1 X chromosome)

/ ""'

23 chromosomes (22 autosomes and 1 Y clvomosome)

~.ild>'~~:=:;r---First polar body containing rest o f chromosomes Secon dary oocyte just before ovulation Second meiotic division begins but Is suspended in cell division unless ovum Is fertlllzed by sperm. Corona radiata ..._.....,

,

.1o··'~"· .,, ..... I·"'

' 4~

/,:'\

\!'"

Zona petlucida? ' -

A

.. •

J

Mature ov um

•

23,X

23,X 23,Y Spermatlds

Mature ovum containing 23 chromosomes (22 autosomes and 1 X chromosome)

23,Y

(

Second polar body 23,X

B

23,X

23,Y

23,Y

Mature s perm

A G 12- 1 Gametogenesis. A, Formation of the mature ovum. B, Formation of mature sperm.

CHAPTER 12 of cytoplasm, plus the other 23 ch romosomes, goes into a tiny, nonfunctional polar body that soon degenerates. At ovulation, thesecondaryoocyte begins dividing again (second meiotic division) to form a mature ovum. The 23 chromosomes duplicate themselves in the second meiotic division, but half of the duplicated chromosomes will be discarded if fertilization occurs. TI1e second meiotic division is prolonged, and the mature ovwn remains suspended in metaphase, the middle part of cell division. lffertilization occurs, the second meiotic division is completed, resulting in a mature ovum containing 23 chromosomes and a second tiny polar body containing the 23 discarded duomosomes tl1at degenerates. If the ovum is not fertilized, it does not complete the second meiotic division and degenerates. In oogenesis, one primaryoocyte result~ in a single mature ovum. When released from the ovary, the mature ovum is surrounded by two la)1ers-the 1.ona pellucida and the cells of the corona radiata. These layers protect the ovum and prevent fertilization by more tlian o ne spe rm. Fo r fertili7..ation to occur, the spe rm must penetrate these two layers to reach the ovuni 's cell nude us.

Spermatogenesis Spemiatogene~is, o r formation of spe rm,

begin s d uring puberty in the male (Figure 12- I, B). Primitive spe rm cells (spermatogonia) develop during fetal li fe and begin multiplying by mitosis during puberty. Unlike the female, the male produces new spermatogonia that can mature into sperm throughout h is li fetime. Although male fertility gradually declines with age, men can father children in their 50s, 60s, and beyond. Each spermatogonium contains 46 paired chromosomes, like other body cells. In the mature male, a spermatogonium enlarges to become a primary spermatocyte, still containing all 46 chromosomes. The first meiotic division forms two secondary spermatocytes and reduces the number to 23 unpaired chromosomes: 22 autosomes and I sex chromosome, either an X or a Y. Ead1 secondary spermatocyte divides again in the second meiotic division LO form two spermatids. Therefore half of the four spermatids that result from the two meiotic divisions of the spermatogonium carry an X chromosome and half c.arry a Y. The spermatids gradually matu re into sperm. The gamete from a male determines the sex of the new baby. If all X- bearing spermatozoon fertilizes the ovum, the baby is a girl. lf a Y- bear ing spermatozoo n fertilizes the ovum, the baby is a boy. Th e mature sperm has th ree sectio ns: a head, a middle portio n, a nd a tail ( Figure I 2·2) . The head is almost entirely the cell nucleus. The head co nta in s the male ch romosomes that jo in the ch romosomes of the ovum. The middle po rtio n supplies energy fo r the ta il's wh ipl ike actio n. The moveme nt of the tail p ropels the sperm toward the ovum.

Conception and Prenatal Development

although the exact durat ion of its viab ility is unknown. Most sperm survive no mo re than I to 2 days alt ho ugh a few may remain fertile in the woman's reproduct ive tract up to 80 hou rs (Blackburn, 2013; Carlson, 2009).

Preparation for Conception in the Female Before ovulation, several oocytes begin to mature under the influence of follicle-stiniulating hormone (FSH ) and luteini7..ing hormone (LH) from tl1e woman's anterior pituitary gland. Eadi maturing oocyte is contained in a sac witliin the ovary called the graafian follicle, which produces estrogen and progesterone to prepare the endometrium (uterine lining) for a possible pregnancy. Eventually one follide outgrows the others. The less mature oocytes permanently regress.

Release of the Ovum Ovulation, or release of tl1e ovwn, occu rs about 14 days before a woman's next menstrual period would begin. The follicle develops a thin spot on the su rface of the ova ry and ruptures, releasing the mature ovw11 with its surround ing cells on the surfu ce o f the ova iy. There the collapsed foJJkle beco mes the corpus luteum, which maintains the high estrogen mid progestero ne secretio n necessary to make final preparatio n of the uterine lin ing fo ra fertiljz.ed ovum.

Ovum Transport Released o n the surface of the ovary, the mature ovum is p icked up by the fimbriated (fringed) ends of the fallopia n tube near the surface of the ovary. The ovum is transported through the tube by muscular action of the tube and movement of cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube, near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovary.

Preparation for Conception in the Male The male preparation for fertilizing tl1e ovum consists of ejaculation, movement of tl1e sperm in tl1e female reproductive tract, and preparation of tl1e sperm for actual fertilization.

Head containing

nucleus with

] 23 chromosomes

Tail

CONCEPTION Conception requires correct timing between release of a mature ovwn at ovulation and ejaculation of enough healthy, mature, motile sperm into the vagina. The ovum may have the capacity to be fertilized no longer than 24 hours after ovulation,

215

FIG 12-2 Mature sperm.

216

CHAPTER 12

Conception and Prenatal Development

Ej ac ul ati on Expulsion of se men from the penis is ejac ulation . When a male ejaculates during vaginal inte rco urse, 35 to 200 million sperm are deposited in the upper vagina and over the cervix (Blackburn, 2013; Hall, 20 11 ; Jones, 2009b). The sperm are suspended in seminal fluid, which nourishes and protects them from the acidic vaginal environment. To hold the semen deeply in the vagina, the seminal fluid coagulates somewhat after ejaculation. The sperm are relatively immobile for about 15 to 30 minutes until other sem inal enzymes dissolve the coagulated fluid and allow the sperm to begin moving upward through the cervix.

Transport of Sperm in the Female Reproductive Tract Whiplike movem ent o f the tails of spermatowa propels them through the cervix, uterus, and fallopian tubes. Uterine contractions induced by prostaglandins in the sem inal fluid enhance movement of the sperm toward the ovum. Onl)' sper m cells enter the cervix. The sem inal flu id remains in the vagina. Many s perm a re lost along the way. Some are d igested by vaginal enzymes and phagocytes in the female rep roductive tract, whereas others move into the wro ng tube o r past the ovum and out into the periton eal cavity. On ly a few hundred reach the fallopian tube where the ovum waits.

Preparation of Sperm for Fertilization Sperm are not immediately ready to fertilize the ovum when they are ejaculated. While making the trip to the ovum, the sperm undergo changes (capacitatio11) that enable one to penetrate the protective layers surrounding the ovum. During capacitation, a glycoprotein coat and seminal proteins are removed from the acrosome (tip of the sperm head). After capacitation, the sperm

look the same but are more active and can better penetrate the corona radiata and zona peUucida that surround the ovum. The sperm that reach the ovum release an enzyme (hyaluronidase) to digest a pathway through the coro na radiata and zona pellucida. Their tails beat harder to propel them toward the center of the ovum. Eventually, one spermatozoon penetrates the ovum.

Fertilization Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents ' chromosomes merge ( Figure 12- 3).

Entry of One Spermatozoon into the Ovum Entry of a spermatozoon into the ovum has two results: Changes in the ?..Ona pellucida su rrounding the ovum prevent other sperm from entering. The ovw11, wh ich has been suspended in the middle of its second meiotic div ision, co mpl etes meiosis. The resul ts are a nucl eus with 23 ch romosomes and exp ulsion of a seco nd no n func tional pola r body. The mat ure ovum now con tains 23 w1paired chromoso mes, 22 autosomes, and 1 X chromosome in its nucleus.

Fusion of the Nuclei of Sperm and Ovum Fusion of the nuclei of th e sperm and ovu m begins when the sperm enters the ovum. The sperm head enlarges, and the tail degenerates. The nuclei of the gametes move toward the center of the ovum, where the membranes surro unding their nuclei touch and dissolve. The 23 chromosomes from the sperm mingle with the 23 from the ovum, restoring the diploid number to 46. Fertilization is complete within 24 hours, and cell division of the zygote can begin when the nuclei of the sperm and ovum unite.

Nucleus of ovum

Fertilizing

sperm Corona radia t a / /

Zona pellucida

A

First and second polar bodies

B

Mixing of cell nuclei and chromosomes of ovum and sperm

C Fertllizatlon complete

AG 12-3 Process of fertilization. A, A sperm enters the ovum. B, The 23 chromosomes from the sperm mingle with the 23 chromosomes from the ovum, restoring the diploid number to 46. C, The fertilized owm, now called a zygote, is ready for the first mitotic cell division.

CHAPTER 12

PRE-EMBRYONIC PERIOD The pre-embryonic period is the first 2 weeks after conception. Figure 12-4 illustrates the period from fertilization through implantation.

Initiation of Cell Division The zygote divides into two cells, then four, then eight cells while in the fallopian tube. Up to the 16-cell stage, the cells become smaller with each division, so they occupy about the same amowlt of space as the original ovum. \Nhen the conceptus (fertilized ovum) is a solid ball of 12 to 16 cells, it is called a morula because it resembles a mulberry. The outer cells of the morula secrete fluid, creating a sac of cells (the blastocysl) that has an inner cell mass within the sac. The inner cell mass of the blastocyst develops into the fetus. Part of the outer layer of blastocyst cells develops into the placenta and fetal membranes.

Entry of the Zygote into the Uterus The con cep tus enters the uterus abo L1t 3 to 4 days after conception, when it co ntains abou t 100 cel ls. It lingers in the uterus another 2 to 4 days befo re begi nning implantation. The endo metrium, now called the decid1111, is in the sec retory phase of the reproductive cycle, J 'h weeks befo re the woma n would begin her menstrual period. The endo metrial glands are secreting at their maximum, provid ing rich fluids to nourish the co nceptus before placental circulatio n is established. The endometrial spiral arteries are well developed in the secretory phase, providing easy access for developing the placental blood supply.

Implantation in the Decidua The conceptus carries a small supply of nutrients for early cell division, but implantation (nidntion) at the proper time and

Conception and Prenatal Development

217

loca tion in the uterus is c rucial for continued developmen t. Complete implantation is a gradual process that occurs between the 6th and 10th days. Embryo nic st ruct ures co ntinue developing during implantation.

Maintaining the Decidua Implantation and survival of the concept us are critically dependent on a continuing supply of estrogen and progesterone to maintain the decidua in the secretory phase. The zygote secretes human d10rionic gonadotropin (hCG) to signal that a pregnancy has begun. With continued hCG production by the conceptus, the corpus luteum continues to secrete estrogen and progesterone ralher Lhan regressing.

Location of Implantation The conceptus must be in the right place at the right time for normal implantation to occur. The site of implantation is important because that is the place that the placenta develops. Normal implantatio n occu rs in the upper uterus (fundus). The upper uterus is the best a rea fo r implantation and placen tal development for three reaso ns: The upper uterus is richly supplied with blood for optimal fetal gas exchan ge