• Rapid (peak) - infancy, adolescence 
• Slows - childhood 
• Minimal physical growth - adult 

1. Respiratory, Digestive, Renal, Musculoskeletal, and Circulatory Tissue = proceed fairly smoothly during childhood.
2. Neurologic tissue =  grows so rapidly the first 2 years that the brain reaches mature proportions by 2 to 5 years. 
3.  Lymphoid Tissue (Spleen, Thymus, Lymph Nodes and Tonsillar Tissue) = grows rapidly during infancy and childhood so children are protected against infection.
4. Reproductive Organs (genital tissue) show little growth until Puberty.

• the largest portion of the mind 
• the center of our primitive instincts and requires immediate gratification. 
• The neonate is the epitome of the id.

• develops in infancy and is the conscious, rational part of the personality; 
• less inward seeking than the id 
• recognizes the larger picture 
• The ego acts as a censor to the id; if there’s a conflict between the id and the ego, neuroses may develop

• represents the person’s conscience and ideals 
• it’s in a continuous battle with the Id 

• Increases during the 1st year by 50%
• Grows from average birth length of 20 inches to about 30 inches (50.8cm to 76.2cm)

• Increases rapidly: reflects brain growth 
• End of 1st year: brain reaches 2/3 of adult size 

• HR slows down to 110-120 bpm by the end of the 1st year 

• RR slows to 20-30 breaths/min 

• Functional by 2 months of age 
• Able to produce IgG & IgM by 1 year of age

• 2 Lower incisors 

• complete by 2-3 years
• shed off by 6-7 y/o 
• replaced by permanent teeth (32) 

• The newborn allows the head to hang down with little effort or control 
• 1 month-old child: can lift the head momentarily
• 3 months: can maintain lifting the head  

• 3 months: when held at ventral suspension, infant's head, legs, & spine extend 
• When head is depressed: hips, knees & elbows flex

• 6-9 months: When infants are suddenly lowered toward a table from ventral suspension, the arms extend as if to protect themselves from falling

• When lying at their stomach, newborns can turn their heads to move it out of the position where breathing is impaired.  

• 4 months: when infant turns the head to the side, shoulders, trunk & pelvis turn in that same direction.

• 1 month: when placed on his/her back & pulled to a sitting position, the child has gross head lag in the first days of life. 
• 6 months: can sit momentarily with support

• Stepping Reflex: In a standing position, the infant's knees & hips flex rather than support more than momentary weight. 
• Fades at 3 months.

• Children double their weight at 4-6 months and triple it at 1 year.
• Infants develop their first tooth at about 6 months
• by 12 months, they have 6-8 teeth
• The more infants are spoken to, the easier it is for them to acquire a language. 
• Providing infants with proper toys for play helps development
• All infant toys need to be checked to be certain they are too large to be aspirated. 

• Safety is important.
• Infants must be protected from falls and aspiration of small objects. 
• A skill of an infant cannot be accomplished in one day but may be accomplished the next. 
• Solid food is generally introduced into an infant's diet at 4-6 months of age. 
• Before they can eat solid food, they must lose their Extrusion Reflex. 

• teething
• thumb-sucking 
• use of pacifiers 
• sleep problems
• constipation 
• colic
• diaper dermatitis 
• baby-bottle syndrome 
• obesity 

•  18 MONTHS 

•  24 MONTHS 

•  30 MONTHS 

• “a little scientist” 
• child experiments by trial and error methods 

• toddlers are able to try out various actions mentally rather than having to actually perform them—the beginning of problem solving or symbolic thought 
• Deferred Imitation = remember an action and imitate it later 

• children deal much more constructively with symbols 
• Assimilation = change the situation (or how they perceive it) to fit their thoughts 

• Automotive accident 
• Burns 
• Falls 
• Poisoning drowning 
• Suffocation and choking 
• Electric shock 
• Animal bites 

• taking a careful health history 
• ability to carry out activities of daily living (ADL) 
• Careful observation 
• child-parent relationship 
• Parents: BEST source of information 

• focus on the parents’ eagerness to learn more about the parameters of normal growth and development or issues of safety or care 
•  Health-seeking behaviors related to normal toddler development 
• Deficient knowledge related to best method of toilet training 
• Risk for injury related to impulsiveness of toddler 
• Interrupted family process related to need for close supervision of 2-year-old 
• Readiness for enhanced family coping related to parents’ ability to adjust to new needs of child 
• Readiness for enhanced parenting related to increased awareness for poison prevention 
• Disturbed sleep pattern related to lack of bedtime routine 

• focus largely on family education and anticipatory guidance 
• establish realistic goals and outcomes so they can meet the rapidly changing needs of their toddler and learn to cope with typical toddler behavior 

• teach parents a good rule is to think of a toddler as a visitor from a foreign land who wants to participate in everything the family is doing but does not know the customs or the language 
• teach parents not only how to approach a current problem but also how to learn adequate methods for resolving similar situations that are sure to arise in the future 
• Health visits provide opportunities to help parents learn healthy coping techniques 
• demonstrating good communication skills with toddlers can serve as a model for healthy communication behavior with them 

• children change so much and learn so many new skills during this time that their abilities and associated parental concerns can change from day to day 
• Parents state child maintains a consistent bedtime routine within the next 2 weeks. 
• Parents state they have childproofed their home by putting a lock on kitchen cupboard by next clinic visit 
• Grandmother states she has modified usual activities to conserve strength to care for toddler granddaughter by 1 week’s time. 

• child develops sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver 
• child should be taught to tolerate frustration through socialization and proper toilet training. 

• Sphincter control begins at age 2 
• All deciduous teeth erupt by 2½ years 
• Pot-bellied appearance 

• parallel play, sand, riding toys, water play, finger paints 

• ignore behavior 
• monitor for safety 

• Offer nutritious snacks 
• May experience food jags 
• Give 6 small meals esp. iron-rich food 
• Avoid giving hotdog, peanuts, and grapes 

• consider readiness, never punish 

• rooming-in, transitional object, offer choices 

• teach parents to place a small amount of food on a plate and allow their child to eat it and ask for more rather than serve a large portion the child cannot finish 
• allowing self-feeding is a major way to strengthen independence
• offering finger foods and allowing a choice between two types of food helps promote independence while exposing children to varied foods

• An individualized task for each child 
• should begin and be completed according to a child's ability to accomplish it, not according to a set of schedule 

• They must have control of rectal and urethral sphincters, usually achieved at the time they walk well. 
• They must have cognitive understanding of what it means to hold urine and stools until they can release them at a certain place and time. 
• They must have a desire to delay immediate gratification for a more socially accepted action.

• use only their spoon at mealtime, only their washcloth at bath time 
• not go outside unless mother or father locates their favorite cap

• do not want to do anything a parent wants them to do 
• reply to every request is a very definite "no"

• setting rules or road signs so children know what is expected of them 
• setting safety limits and protecting others or property 

• Punishment = is a consequence that results from a breakdown in discipline, from the child's disregard of the rules that were learned. 
• Timeout = is a technique to help children learn that actions have consequences 

• fear of being separated from parents begins at about 6 months of age and persists throughout the preschool period. 

• kick, scream, stamp feet, shout "No, no, no" lie on the floor, flail arms and legs, and bang the head against the floor.

• Provocation = usually provoked-parent can state a reason for it (she asked toddler to come to dinner, toddler wanted to finish an activity 
• Appearance of Cyanosis: Child holds breath, becomes cyanotic, then slumps to floor 

• Provocation = Usually provoked; child very angry; child breathes out and forgets to breathe in 
• Appearance of Cyanosis = child breathes out, becomes cyanotic, then slumps to floor

• Provocation = not provided
• Appearance of Cyanosis = child slumps to floor first, then becomes cyanotic

• an important period of growth for parents 
• Setting limits 
• the physical growth slows considerably during this period, personality and cognitive growth continue at a rapid rate

•  4 YEARS OLD 

•  5 YEARS OLD 

• If children are criticized or punished for attempts at initiative, they develop a sense of guilt for wanting to try new activities or have new experiences 
• need exposure to a wide variety of experiences and play materials so they can learn as much about the world as possible 
• ready to reach outside their homes for new experiences, such as a trip to the zoo or an amusement park 

• Significant others now include grandparents, siblings, and preschool teachers (although parents remain central) 
• Regular interaction with same-age children is necessary to further develop social skills 

• need free rein to imitate the roles of the people around them 
• role playing should be fun and does not have to be accurate 
• imitate those activities best that they see their parents performing at home 

• begin to make this differentiation 
• become so engrossed in a fantasy role, however, they become afraid they have lost their own identity or have become “stuck” in their fantasies 
• both supporting the fantasy and yet reassuring a child she is still herself 
• let children know they are still recognizable 

• Each child competes with the same-sex parent for the love and attention of the other parent 
• Parents may need help in handling feelings of jealousy and anger if a child is vocal in expressing feelings toward a parent 

• need exposure to an adult of the opposite gender so they can become familiar with opposite gender roles
• Encourage single parents to plan opportunities for their children to spend some time with adults other than themselves, such as a grandparent, a friend, or a relative of the opposite sex, for this exposure 

• play with other children their age much more 
• sensitive and critical time for socialization 
• Four-year old, involving some testing and identification of their group role 
• Five-year-olds begin to develop “best” friendships, perhaps on the basis of who they walk to school with or who lives closest to them 
• Elementary Rule: an odd number of children will have difficulty playing well together pertains to children at this age: two or four will play, but three or five will quarrel 

• Watch adults and imitate behavior 
• Imaginative= imaginary playmates 
• Creative and curious = WHY, HOW 
• Offensive language 
• Oedipal/electra complex 
• Sibling rivalry • “sex” – be honest’ 
• Masturbation may be seen 
•  Egocentrism increases 
• Play more related to real-life events (associative or cooperative) 
• Basic curiosity results in constant questions and improved reasoning ability 
• Language development more elaborate 

• 3 years, cognitive development according to Piaget is still preoperational 
• enter a second phase called intuitional thought (intuitive thought phase) 
• Centering = lack the insight to view themselves as others see them or put themselves in another’s place; an important point to remember when explaining procedures to preschoolers 
• not yet aware of the property of conservation 
• Implications: not able to comprehend that a procedure done two separate ways is the same procedure 

• determine right from wrong based 
• on their parents’ rules 
• have little understanding of the rationale for these rules or even whether the rules are consistent 
• depend on their parents to supply rules for them, thus, with difficulty seeing that the rules they know may also apply to a new situation 
• begin to have an elemental concept of God if they have been provided some form of religious training 
• Belief in an outside force aids in the development of conscience

• heightened by a child’s vivid imagination 
• Night waking from nightmares or night terrors reaches its peak 
• Night light = reassurance they are safe, that whatever was chasing them was a dream and is not in their room 
• source of the stress needs to be investigated 

• revealed by the intense reaction of a 
• preschooler to even a simple injury such as falling and scraping a knee or having a needle inserted for an immunization 
• need good explanations of the limits of health care procedures 
• fear of castration 

• intensifies because their keen imagination allows them to believe they have been deserted when they are safe 
• Relating time and space to something a child knows, such as meals, television shows, or a friend’s house, is most effective 
• A hospital admission or going to a new school often brings a child’s fear of separation

• Caution parents not to encourage the kind of storytelling, but instead help the child separate fact from fiction 
• Imaginary Friends = separate fact from fantasy about their imaginary friend 

• Assure parents that sharing is a difficult concept to grasp and that, as with most skills, preschoolers need practice to understand and learn it 
• Defining limits and exposing children to these three categories (mine, yours, ours) helps them determine which objects belong to which category 

• in relation to stress, revert to behavior they previously outgrew, such as thumbsucking, negativism, loss of bladder control, and inability to separate from their parents 
• new baby in the family 
• a new school experience 
• seeing frightening and graphic television news 
• stress in the home from financial or other problems, marital difficulties 
• separation caused by hospitalization 
• removing the stress is the best way to help a child discontinue this behavior 
• Thumb-sucking or other manifestations of stress are best ignored 

• A firstborn child is rarely allowed the privileges of a second child. The parents were untried, unsure of how far they should let a child venture or what level of responsibility a child could accept when the child was younger, or the firstborn serves as the “trial run” for all children who come after 
• feel secure and promote self-esteem, by supplying them with a private drawer or box for their things that parents or other children do not touch can be helpful 

• obtaining a health history and performing both a physical and developmental evaluation 
• history that details their usual performance level is therefore very important for accurate evaluation 
• child’s weight and height according to standard growth charts 
• assess a child for general appearance 
• Alert? Happy? Active? Healthy 
• Child can play actively without becoming exhausted 
• Assess the teeth for presence of cavities 
• Evaluate for a symmetrical gait 
• Frequent upper respiratory infections 

• Health-seeking behaviors related to developmental expectations 
• Readiness for enhanced parenting related to parent’s pride in child 
• Delayed growth and development related to frequent illness 
• Risk for poisoning related to maturational age of child 
• Parental anxiety related to lack of understanding of childhood development 
• Risk for injury related to increased independence outside the home
• Imbalanced nutrition related to child's many food dislikes 

• establishing a schedule for discussing normal preschool development with the parents 
• done at all health maintenance visits  
• accident prevention 
• plan opportunities for adventurous activities or messy play 

• children imitate moods as well as actions – important nursing intervention 
• role-playing a mood or attitude you would like a child to learn – health assessment is an enjoyable activity 
• suggest preschoolers participate by listening to their heart or coloring the table paper – Accident prevention is also best taught by role modeling 
• a parent always crosses streets at the corner and does not start the car until seatbelts are in place 

• Child states importance of holding parent’s hand while crossing streets 
• Parent states realistic expectations of 3-year-old’s motor ability by next visit. 
• Mother reports she has prepared 4-year-old for new baby by next visit 

• refers to the stage of a child’s life from ages 6 to 12 years 
• The school-age years can be a spectacular journey filled with joys and successes as the child continues to grow and mature 
• time of slow physical growth, cognitive growth and development continue to proceed at rapid rates 
• always assess children as individuals to understand the particular developmental needs of each child based on what developmental status has been achieved, not on what stage you think the child should have reached 
• Children of school age may be more influenced by the attitudes of their friends 
• the first time children begin to make truly independent judgments 

• brain growth is complete, so fine motor coordination becomes refined 
• adult vision level is achieved 

• malocclusion (a deviation from the normal) with teeth malalignment

• Appendicitis 
• Frontal sinuses develop at about 6 years =  sinus headache 

• increases exertion ability and stamina

•  over age 8 should be screened 

• in girls usually occurs between 12 and 18 years; in boys, between 14 and 20 years gonadal hormone levels increase and cause the sexual organs to mature 
• onset of puberty varies widely, between 10 and 14 years of age 

• 12-13 years old

• 11-12 years old 

• 9-11 years old

• 11-12 years old 

• 12-13 years old

• 9-11 years old

• time for parents to discuss with children the physical changes that will occur and the sexual responsibility these changes dictate 
• time to reinforce previous teaching with children that their body is their own, to be used only in the way they choose 

• Prepubertal girls are usually taller, by about 2 in (5 cm) or more than preadolescent boys 
• girl notices the change in her pelvic contour when she tries on a skirt or dress from the year before and realizes her hips are becoming broader 
• Crash diet 
• Girls are usually conscious of breast development and whether they are overdeveloped or underdeveloped 
• Breast self-examination and sexual responsibility 

• Supernumerary (additional) nipples may darken or increase in size at puberty 
• Early preparation for menstruation is important for future childbearing and for the girl’s concept of herself as a woman 
• good hygiene and reassurance they can bathe, shower, and swim during their periods 
• use either sanitary napkins or tampons 
• take precautions to avoid toxic shock syndrome 

• first menstruation, called menarche, usually starts around age 12 but can occur as early as age 9 and still be considered normal 
• The menstrual cycle may be irregular at first 
• consistent irregularities in her period should be assessed for malnourishment and obesity 
• Emotions 
• if irregularity continues beyond the first year, a careful history of the girl’s school, social, nutrition, level of exercise, and home adjustment should be taken 
• vaginal secretions will begin to be present 
• Explain that any secretions that cause vulvar irritation should be evaluated 

• aware of increasing genital size 
• testicular development precedes penis growth 
• be informed that hypertrophy of breast tissue (gynecomastia) can occur in prepuberty (most often in stocky or obese boys) 
• although they have pubic hair, they cannot yet grow a beard or do not have chest hair 
• seminal fluid is produced, boys begin to notice ejaculation during sleep, termed nocturnal emissions  

• Brain reaches 90% to 95% of adult size, nervous system almost mature by age 12 
• Motor abilities progress to writing in script and in sentences by age 12 
• Sexual organs grow but are dormant until late in this period 
• All permanent teeth present except for 2nd and 3rd molars by age 12 
• The average child gains 28 teeth between 6 and 12 years of age: the central and lateral incisors; first, second, and third cuspids; and first and second molars 

• Attending school marks an acceleration in the separation of the child from his parents 
• introduces the child to a new set of authority figures (teachers, school administrators) and strengthens the concept of peer relationships 

• Erikson’s stage of industry versus inferiority 
• child wants to work and produce, accomplishing and achieving tasks 
• focus on learning useful skills, self-identity emerges 
• if too much is expected of him, or if he feels unable to measure up to set standards, the negative attributes of inadequacy and inferiority may prevail

• child has an efficient vocabulary and begins to correct previous mistakes in usage 
• begins to understand the double meanings of words and becomes proficient at giving others directions without using physical signals 

• define objects by their use: a key is to unlock a door; a fork is to eat with  

• know the months of the year and can name the months in which holidays fall 
• can add and subtract and make simple change 

• discover “dirty” jokes 
• Like to tell them to friends or try to understand those told by adults 
• use swear words to express anger or just to show other children they are growing up 
• have a short period of intense fascination with “bathroom language” 

• a sense of humor is apparent 
• can carry on an adult conversation, although stories are limited because of their lack of experience 

• peers are increasingly significant to the child
• Same-sex cliques are established
• competition becomes more common 
• bragging over accomplishments 
• child may be overly concerned with peer rules 
• more sensitive to criticism and ridicule 

• continues to be rough at age 6 
• when children discover reading as an enjoyable activity that opens doors to other worlds, they can begin to spend quiet time with books 
• Many children spend hours playing increasingly challenging video games, an activity that can either foster a healthy sense of competition or create isolation from others 

• decline in imaginative play 
• interest in collecting items such as baseball cards, dolls, rocks, or marbles 

• collections may become increasingly structured as children develop skills for sorting and cataloging 

• children become very interested in rules and fairness in competitive play situations 

• Children also begin discovering the Internet and how other children out there are waiting to talk to them in chat rooms 
• Music and artistic expression 

• In Piaget’s concrete operational stage, organizing facts and problem-solving 
• Uses inductive reasoning to solve new problems 
• Thinks logically and develops concepts of measurement 
• Generalizes about people, places, and things 
• Develops classification systems, understands reversal of events 
• Has an awareness of other’s feelings 

• Decentering 

• Accommodation

• Conservation 

• Class Inclusion 

• Decentering enables a school-age child to feel compassion for others, which was not possible in younger years 
• Understanding Conservation is possible, a school-age child is not fooled by perceptions as often as before; because of this, sibling arguments over food (your piece of pie is bigger than mine, his glass of cola is bigger than mine) 
• The ability to classify objects leads to the collecting activities of the school-age period 
• Class inclusion is also necessary for learning mathematics and reading, systems that categorize numbers and words  

• ability to trust others and with a sense of respect for their own worth 
• can accomplish small tasks independently because they have gained a sense of autonomy 
• have practiced or mimicked adult roles and had the opportunity to explore at preschool or other social environments 
• should have learned to share, to have discovered that learning is fun and an adventure 

• child behaves according to socially acceptable norms because an authority figure tells him to do so 
• This obedience is compelled by the threat of punishment (external factors) 

• as the child begins to approach adolescence, school and parental authority is questioned and, occasionally, even challenged or opposed 
• importance of the peer group intensifies, and rough, bold, or even brazen behavior becomes increasingly common 
• peer group becomes the source of behavior standards and models 

• child at this age needs the opportunity to make decisions within defined boundaries 
• those boundaries are set by responsible adults in the child’s life 
• Spiritual lessons should be taught in concrete terms during this stage 
• Repeated religious rituals, such as praying and attending church services, may comfort them 

• begin to learn about the rituals and meaning behind their religious practices, so the distinction between right and wrong becomes more important 
• Parent role modeling is also important 
• school-age children are rule-oriented; when they pray, they may expect their God to follow rules also (if you are good and pray for something, you should receive it) 

• Proper nutrition 
• Exercise 
• Dental hygiene 
• Sleep 

• encouraged to eat a variety of healthy foods, such as lean meats, fruits, vegetables, and grains, to ensure proper nutritional intake 
• Encouraging healthy eating habits now (during school age and ideally, before) will lay a stable foundation for adolescence, when caloric needs increase 
• Childhood obesity is increasing, and measures should be taken to avoid high-fat, high-sugar, low-protein foods 

• stock the pantry and refrigerator with healthy choices for afterschool snacks (raw vegetables, low-fat yogurts, fresh fruits) 
• avoid taking children to fast-food establishments where high-fat foods are abundant 
• teach children how to read nutrition labels while shopping at the grocery store 
• involve children in planning and preparing meals for the family 
• offer candy and other sweets as an infrequent privilege rather than a reward for good behavior
• change their own eating habits to model good dietary habits for their children 

• Encouraged 
• to help the child begin healthy habits for a lifetime
• prevent childhood obesity 
• sport teams or sporting events 
• same-sex events, making them less intimidating 

• Teeth should be brushed at least twice a day and, if possible, after meals 
• Drinking water should contain fluoride or fluoride supplements should be given 
• Flossing should be taught, and parents should monitor for method and compliance until the child is 8 years old 
• Regular dental cleanings should be scheduled every 6 months 

• Requirements for sleep and rest are unique and relate to the child’s activity level and physical health 
• generally don’t require an afternoon nap, and compliance at bedtime becomes easier
• Children should develop healthy sleep habits by not having a television in their bedrooms 

• Sleepwalking and sleep talking may begin during this stage, and parents should take measures to ensure the child’s physical safety during these episodes. 
• Nightmares are usually related to a real event in the child’s life and can usually be eradicated by resolving any underlying fears the child might have 

• called school refusal or school avoidance 
• may be a sign of a separation anxiety 
• occur after a particular trauma, such as the death of a pet, illness within the family, or a move to a new school 
• fear of the school itself and what the child experiences there 
• Possible reasons for school phobias include: 

• simply wants items for himself 
• Stealing at the end of middle childhood is commonly a sign that something is lacking in that child’s life 
• Possible causes include a lack of: 

• Parents should recognize the child’s property rights and offer some privacy in this regard, when possible 
• A child who knows that his own property is respected is more likely to understand the importance of respecting the property of others 

• history and physical examination to assess growth and development 
• school activities and progress 
• Interview children 10 years or older at least in part without their parents present 

• Health-seeking behaviors related to normal schoolage growth and development 
• Readiness for enhanced parenting related to improved family living conditions 
• Anxiety related to slow growth pattern of child 
• Risk for injury related to deficient parental knowledge about safety precautions for a school-age child 
• Imbalanced nutrition, more than body requirements, related to frequent consumption of snack foods
• Delayed growth and development related to speech, motor, psychosocial, or cognitive concerns

• children tend to enjoy small or short term projects rather than long, involved ones 
• Behavior problems need to be well defined before outcomes are identified and interventions planned

• more comfortable if they know the “hows” and “whys” of actions
• May not cooperate with a procedure until they are given a satisfactory explanation of why it must be done 
• watch you to see your attitude as well as your actions in a given situation

• parents to look back on problems identified at the last visit and discuss if and how they were resolved 
• Parent states he allows child to make own decisions about how to spend allowance 
• Child lists books she and her parents have read together in past 2 weeks 
• Child states he understands his growth is normal, even though he is the shortest boy in his eighth-grade class 
• Child does not sustain injury from sports activities during the summer recess    

• Apocrine sweat glands 
• heart and lungs increase in size more slowly than the rest of the body 
•  PR:70 beats per minute RR: 20 breaths per minute BP: 120/70 mm Hg 
• Major milestone: Onset of puberty at 9 to 12 years of age and the cessation of body growth at 16-20 years of age 

• Girls: begins to menstruate 
• Boys: begins to produce spermatozoa 
• puberty is the time at which an individual first becomes capable of sexual reproduction 

• STALKING
• HAZING 

• REFERS TO THE USE OF CHEMICALS TO IMPROVE A MENTAL STATE OR INDUCE EUPHORIA 

• SUICIDE 

• RUNAWAY 

• young adulthood = young adults are defined as people 20 to 40 years old 
• middle adulthood = middle-aged adults as 40 to 65 years old 
• late adulthood 

• Baby Boomers (born in years 1945–1964) 
• Generation X (birth years 1965–1978) 
• Generation Y or the Millennials (birth years 1979–2000) 

• Human body is at its most efficient functioning at about age 25 years 
• musculoskeletal system is well developed and coordinated 
• period when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency 
• physical changes are minimal during this stage, weight and muscle mass may change as a result of diet and exercise. 
• extensive physical and psychosocial changes occur in pregnant and lactating women 

• psychosocial development of the young adult is great 
• basic developmental task is establishing intimacy or very close friendship 
• Occupational choice and education are largely inseparable 
• sense of intimacy versus isolation 

• Young adults are able to use formal operations, characterized by the ability to think abstractly and employ logic 
• For example, young adults are able to generate hypotheses about what will happen, given a set of circumstances and do not have to engage in trial-and-error behavior 

• Young adults who have mastered the previous stages of Kohlberg’s theory of moral development enter the postconventional level 
• At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles
• When individuals perceive a conflict with society’s rules or laws, they judge according to their own principles 

• According to Fowler (1981), the individual enters the individuating reflective period sometime after 18 years of age 
• the individual focuses on reality 
• The religious teaching that the young adult had as a child may now be accepted or redefined 

• Young adulthood is generally a healthy time of life 
• Health risks that do occur and are common in this age group include: injury and violence, Suicide, hypertension, substance abuse, sexually transmitted infections (STIs), eating disorders, certain malignancies 

• The leading causes of death differ among the various population groups.
• For example, unintentional injuries (primarily motor vehicle crashes) are the fifth leading cause of death for the total population but the leading cause of death for people 1 to 44 years of age 

• leading cause of death in the young adult age group (Edelman & Mandle, 2010, p. 585) 
• Many suicides may actually be mistaken for accidental death (motor vehicle crashes, combining alcohol and barbiturates, or discharging a gun while cleaning it) 

• major problem for young African American adults, particularly men 
• Many of the causes for this higher incidence of hypertension are unknown 

• major threat to the health of young adults 
• Alcohol, marijuana, amphetamines, and cocaine, for example, can bring about feelings of well-being that may be highly valued by people with adjustment problems 

• STIs such as genital herpes, AIDS, syphilis, and gonorrhea are common infections in young adults 

• Many young adults battle with obesity 
• According to Healthy People 2020 goals and objectives for nutrition and weight status all Americans will avoid unhealthy weight gain (USDHHS, 2010a) 

• Testicular cancer is the most common neoplasm in young men 
• Seminoma testicular cancer most commonly affects men ages 30 to 45 

• Assessment guidelines for the growth and development of the young adult are shown in the accompanying Developmental Assessment Guidelines 
• Young adults are usually interested in meeting their health needs 
• because of the many stresses and changes that occur throughout the 20-year period from ages 20 to 40, the nurse needs to offer teaching and guidance in several health care areas 

• A number of changes that start when young adults are in their mid-20s become noticeable as the fifth decade approaches 
• At 40, most adults can function as effectively as they did in their 20s 
• However, during ages 40 to 65 many physical changes take place 

• Erikson viewed the developmental choice of the middle-aged adult as Generativity versus Stagnation 
• Generativity is defined as the concern for establishing and guiding the next generation 
• the concern about providing for the welfare of humankind is equal to the concern of providing for self

• The middle-aged adult’s cognitive and intellectual abilities change very little 
• Cognitive processes include reaction time, memory, perception, learning, problem-solving, and creativity. 

• According to Kohlberg, the adult can move beyond the conventional level to the post-conventional level 
• Kohlberg believed that extensive experience of personal moral choice and responsibility is required before people can reach the post-conventional level  

• Not all adults progress through Fowler’s stages to the fifth, called the paradoxical-consolidative stage. 
• At this stage, the individual can view “truth” from a number of viewpoints 

• Leading causes of death in this age group include motor vehicle and occupational injuries, chronic disease such as cancer and cardiovascular disease 

• Changing physiological factors, as well as concern over personal and work-related responsibilities, may contribute to the injury rate of middle-aged people 

• Cancer is the leading cause of death in middle adulthood 

• Heart disease and cancer are the leading causes of death during middle adulthood

• Middle-aged adults who gain weight may not be aware of some common facts about this age period  

• excessive use of alcohol can result in unemployment, disrupted homes, injuries, and diseases

• Developmental stressors, such as menopause, the climacteric, aging, and impending retirement, and situational stressors, such as divorce, unemployment, and death of a spouse, can precipitate increased anxiety and depression in middleaged adults  

• Assessment guidelines for the growth and development of the middle-aged adult are shown in the accompanying Developmental Assessment Guidelines 
• Middle-aged adults usually take care of their health needs and are interested in maintaining health and preventing the acceleration of the aging process 

• Three distinct generations are included in adulthood: baby boomers, Generation Xers, and Generation Ys. Each group has its own worldview. 
• Emerging and young adults develop a self-identity and prepare for intimate relationships with others. 
• Moral development continues throughout adulthood.
• Health risks for young adults are primarily related to lifestyle and behavior. 
• Midlife adults begin to notice physical changes associated with aging. 
• The developmental issue for midlife adults is generativity. 
• Adults in midlife must balance the needs of many, including their own parents and children 
• Health decisions made by midlife adults may affect their health in later life. 
• A variety of health threats, including cancer and heart disease, begin to affect individuals in their middle age 
• Physical activity, healthy nutrition choices, and routine care by a health provider are important throughout the adult years. 

• Because of the increase in numbers, nurses will be caring for older adults at some point 
• It is important for nurses to be aware of their own values and attitudes toward aging, and examine whether myths or stereotypes influence those attitudes 

• is used to describe negative attitudes toward aging or older adults (Mauk, 2014, p. 10) 
• Ageism is discrimination based solely on age 

• Ageism contributes to the development of negative stereotypes about older adults 
• Stereotypes occur when younger people do not understand or identify with older adults as unique human beings 
• important for nurses to provide accurate information about aging 
• an effective intervention for reducing negative stereotypes and improving attitudes about aging 

• Educate
• Emphasize the importance 
• Ensure privacy and comfort
• Engage and involve

• Health history
• Physical exam
• Diagnostic test
• Health education

• Set up and plan the interview well
• Guide the client in answering
• Verify information

• Review past pregnancies
• Obtain the OBSTETRIC SCORE
• Determine the EDD & AOG

• Normal weight gain all throughout pregnancy is 30-35 lbs
• Sudden increase in BP and weight gain is a danger sign of HYPERTENSION
• Sudden increase in PR or RR may suggest BLEEDING

• Pelvic examination
• Papanicolau smear
• Pelvic measurement

• Prepare needed equipment
• Help the patient to relax
• Position the woman correctly: lithotomy position with pillow under her head and ask to void
• DRAPE and ask to remain in the same position for a short time after the procedure
• Allow support people
• If desired, allow to watch the pelvic examination

• Endocervical
• Cervical os
• Vaginal pool

• Done during the first pregnancy

• CBC
• VDRL - blood test for venereal diseases (specifically syphilis)
• Blood Typing. RH (Indirect Coombs test)
• MSAFP - if there’s a problem with the spine of the child
• Antibody titer for rubella and Hepatitis
• HIV screening
• 50g OGTT

• PPD / Tuberculin skin test
• Chest X-ray

• PROBABLE 

• POSITIVE 

• The size (length, depth, width, weight, wall thickness and volume). steadily increases and is predictable depending on the week of pregnancy. 
• The exact shape of the uterus is influenced by the position of the fetus inside. 
• It is measured from top of the symphysis to the top of the uterine fundus 

• INCREASED Progesterone and Estrogen→ halt in production of FSH and LH 
• INCREASED production of growth hormone and melanoctye stimulating hormone 
• Produces Oxcytocin late in pregnancy, as well as prolactin production 

• Lumbar curvature 
• Enlargements of the uterus 
• RELAXIN 

• the environment in which she was raised 
• the messages about pregnancy her family communicated to her as a child 
• the society and culture in which she lives as an adult 
• whether the pregnancy has come at a good time or less than a good time in her life 

•  continuing to work with other health care providers to “demedicalize” childbirth 
•  informing women about their new health care options 

• ask at prenatal visits if there is anything they believe should or should not be done to make the pregnancy successful and keep the baby healthy 
• Lifting arms over the head may cause twisting of the cord 
• Watching lunar eclipse may cause birth deformities 
• Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health 

• Ability to cope with or adapt to stress 
• Relationship with people around 
• “brides” as young, “mother” as old 
• Express feelings and become aware of intensity to resolve 

• First 2 weeks, beginning with fertilization
• Ends at implantation, which occurs on day 7 post-conception
• Period of pre-differentiation of organs
• Includes fertilization, cleavage of oocyte, and formation of blastocyst
• The conceptus is transported from the ovary, through the oviduct, into the uterine cavity
• When exposed to a teratogen, “all” or “none” law applies
• Ovum is damaged and is out in spontaneous abortion or
• Not affected at all and continues to grow normally

• Weeks 3 through 8
• Begins with blastogenesis (i.e., formation of germ layers)
• Period of organ differentiation (organogenesis)
• Most dangerous period
• A teratogen introduced may result in severe organ malformation and dysfunction

• From 8 weeks to birth 
• Period of post-differentiation of organs
• When exposed to teratogen: malformation is least likely to occur
• If ever the fetus is affected, the effects will be most likely be alteration in size or function

• Outer of the two covering layers
• Layer of cells produces various placental hormones, such as hCG, somatomammotropin (human placental lactogen [hPL]), estrogen, and progesterone

• Middle layer
• Present as early as 12 days’ gestation
• Function early in pregnancy to protect the growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis
• Disappears, however, between the 20th and 24th weeks

• If a placenta is smaller, circulation to the fetus may have been inadequate.
• If placenta is larger, circulation to the fetus was threatened, because it suggests that the placenta was forced to spread out in an unusual manner to maintain a sufficient blood supply
• The fetus of a woman with diabetes may also develop a larger-than-usual placenta from excess fluid collected between cells

• Metabolic gas exchange begins at 4 weeks
• Funic souffle soft blowing heard over umbilical cord – synchronous with fetal heartbeat, hearing bloodflow through vessel
• Uterine souffle heard just above mother’s pelvis – synchronous with maternal pulse

• This position lifts the uterus away from the inferior vena cava, preventing blood from being trapped in the woman’s lower extremities
• If the woman lies on her back and the weight of the uterus compresses the vena cava, placental circulation can be so sharply reduced that supine hypotension (very low maternal blood pressure and poor uterine circulation) occurs

• Forms a barrier between mother and embryo (blood is not exchanged)
• Delivers nutrients and oxygen
• Removes waste from embryonic blood
• Becomes an endocrine organ (produces hormones) and takes over for the corpus luteum
• Estrogen
• Progesterone
• Other hormones that maintain pregnancy

• First placental hormone produced
• Can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred) through about the 100th day of pregnancy
• A false-negative result from a pregnancy test may be obtained before or after this period
• Blood serum will be completely negative for hCG within 1 to 2 weeks after birth
• Testing for hCG after birth can be used as proof that placental tissue is no longer present

• Act as a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen
• Play a role in suppressing the maternal immunologic response so that placental tissue is not detected and rejected as a foreign substance
• The structure of hCG is similar to that of luteinizing hormone of the pituitary gland, if the fetus is male, it exerts an effect on the fetal testes to begin testosterone production
• Presence of testosterone causes maturation of the male reproductive tract
• 8th week of pregnancy, the outer layer of cells of the developing placenta begins to produce progesterone, making the corpus luteum
• The production of hCG, which sustained the corpus luteum, begins to decrease

• Primarily estriol
• Produced as a second product of the syncytial cells of the placenta
• Contributes to the woman’s mammary gland development in preparation for lactation and stimulates uterine growth to accommodate the developing fetus
• Referred to as the “hormone of women”

• The “hormone of mothers”
• Necessary to maintain the endometrial lining of the uterus during pregnancy
• Present in serum as early as the fourth week of pregnancy, as a result of the continuation of the corpus luteum
• After placental synthesis begins (at about the 12th week), the level of progesterone rises progressively during the remainder of the pregnancy
• Appears to reduce the contractility of the uterus during pregnancy, preventing premature labor
• Reduced contractility is probably produced by a change in electrolytes (notably potassium and calcium), which decreases the contraction potential of the uterus

• hPL is a hormone with both growth-promoting and lactogenic (milk-producing) properties
• Produced by the placenta beginning as early as the sixth week of pregnancy, increasing to a peak level at term
• Can be assayed in both maternal serum and urine
• Promotes mammary gland (breast) growth in preparation for lactation  
• Serves the important role of regulating maternal glucose, protein, and fat levels so that adequate amounts of these nutrients are always available to the fetus

• Outer most membrane
• Fingerlike projections, “villi”

• Thin protective membrane
• Contains amniotic fluid

As embryo grows, amnion comes in contact with chorion and forms fluid filled sac.

• Produces a phospholipid that initiates the formation of prostaglandins
• Can cause uterine contractions and may be the trigger that initiates labor
• Occasionally, fibrous amniotic bands that can constrict an arm or leg of the fetus form in utero
• Can close off the blood supply to the distal extremity and cause growth of the extremity to halt at that point 

• Protection
• Temperature regulation
• Protects the umbilical cord from pressure
• Protecting the fetal oxygen supply
• Aids in muscular development
• Gives freedom of movement

• Major method of absorption
• The fetus continually swallows the fluid
• In the fetal intestine, it is absorbed into the fetal bloodstream --> it goes to the umbilical arteries and to the placenta, and it is exchanged across the placenta
• At term, the amount of amniotic fluid has increased so
  much it ranges from 800 to 1200 cc

• Excessive amniotic fluid
• More than 2000 mL in total, or pockets of fluid larger
• Than 8 cm on ultrasound

• Reduction in the amount of amniotic fluid
• Less than 300 cc, no pocket on ultrasound larger than 1 cm
• Disturbance of kidney function

• To transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta
• About 53 cm (21 in) in length at term and about 2 cm
  (3⁄4 in) thick
• Bulk of the cord is a gelatinous mucopolysaccharide
  called Wharton’s jelly ; gives the cord body and prevents pressure on the vein and arteries that pass through it
  - outer surface is covered with amniotic membrane

• Rate of blood flow through an umbilical cord is rapid (350 mL/min at term) ; it is unlikely that a cord will twist or knot
  enough to interfere with the fetal oxygen supply.
• 20% of all births, a loose loop of cord is found around the fetal neck (nuchal cord) at birth ; If this is removed before the newborn’s shoulders are born, there is no traction in it, the oxygen supply to the fetus remains unimpaired.
• Adequacy of blood flow (blood velocity) can be determined by ultrasound examination during pregnancy
• Blood can be withdrawn from the umbilical vein or transfused into the vein during intrauterine life for fetal assessment or treatment (termed percutaneous umbilical blood sampling [PUBS]).
• Walls of the umbilical cord arteries are lined with smooth muscle
• Constriction of these muscles after birth contributes to hemostasis and helps prevent hemorrhage of the newborn 
• Because the umbilical cord contains no
  nerve supply, it can be cut at birth
  without discomfort to either the child or
  woman

as a fetus grows, body organ systems develop from specific tissue layers called germ layers

1. The ectoderm gives rise to the nervous system and the epidermis, among other tissues. 
2. The mesoderm gives rise to the muscle cells and connective tissue in the body. 
3. The endoderm gives rise to the gut and many internal organs.

• to provide a source of red blood cells until the embryo’s hematopoietic system is mature enough to perform this function 
• yolk sac then atrophies and remains only as a thin white streak discernible in the cord at birth

• (the end of the embryonic period) 
• all organ systems are complete, at least in a rudimentary form 

• the growing structure is most vulnerable to invasion by teratogens 
• factor that adversely affects the fertilized ovum, embryo, or fetus 

• Fetus depends on placenta to meet Oxygen needs while organs continue formation 
• Oxygenated blood flows from the placenta to the fetus via the umbilical vein

• 2 umbilical arteries: carry or return deoxygenated blood, fecal waste, CO2 from the fetus to the placenta 
• 1 umbilical vein: brings oxygenated blood and nutrients from the placenta to the fetus

• respiratory center for the fetus 
• water, glucose, amino acids, vitamins, and inorganic salts freely diffuse across the placenta along with oxygen 

1. Ductus arteriosus - protects lungs against circulatory overload; allows the right ventricle to strengthen 
2. Ductus venosus - fetal blood vessel connecting the umbilical vein to the IVC 
3. Foramen ovale - shunts highly oxygenated blood from right atrium to left atrium

• Length: 2.5 cm, weight: 20 g 
• Organogenesis is complete 

• Length: 7-8 cm, weight: 45 g 
• Nail beds are forming 

• Length: 10-17 cm, weight: 55-120g 
• FHT by stethoscope 
• Lanugo is well formed 
• Liver and pancreas are functioning 
• Sex can be determined by ultrasound 

• Length: 25cm, weight: 223 g 
• Hair forms including eyebrows and on the head 
• Meconium is present in the upper intestine 
• Vernix caseosa begins to form and cover the skin 

• Length: 28-36cm, weight: 550g 
• Meconium is present as far as the rectum 
• Active production of lung surfactant begins 

• Length: 35–38 cm; Weight: 1200 g 
• Lung alveoli begin to mature and surfactant can be demonstrated in amniotic fluid 

• Length: 38–43 cm; Weight: 1600 g 
• Subcutaneous fat begins to be deposited 
• Little old man appearance is lost 
• Fetus responds by movement to sounds outside the mother's body 

• Length: 42-48 cm, weight: 1800-2700g 
• Body stores of glycogen, iron, carbohydrate, and calcium are deposited 
• Additional amounts of subcutaneous fat are deposited 

• Length: 48–52 cm (crown to rump, 35–37 cm); Weight: 3000 g (7–7.5 lb) 
• Kicks hard enough that causes discomfort to the mother 
• Fetal hgb to adult hgb so rapid that about 20% of hgb is adult in character 

• Uterine Muscle Stretching Releasing Prostaglandins 
• Cervical Pressure Causing Release of Oxytocin 
• Oxytocin and Progesterone Balance 
• Placental Aging 
• Fetal Cortisol and Prostaglandin

• Occurs 10-14 days before labor begins (primiparous women, 2 weeks before)
• Relief of shortness of breath from the lungs but now presses more on the bladder

• Felt first abdominally & remain confined to the abdomen & groin 
• Often disappear with ambulation & sleep 

• It is related to an increase in epinephrine release – prepares a woman’s body for the work of labor ahead
• Do not encourage, they must not expend their energy, rest instead (conserve)

• Goodell’s sign - all throughout pregnancy, cervix has the same consistency as the earlobe 
• At term, it becomes still softer & described as “butter-soft” 

• Begin irregular but become regular & predictable
• Sweeps around to the abdomen 
• Continue no matter what 
• Increase in duration, frequency & intensity
• Achieve cervical dilatation

• Mucus plug that filled the cervical canal is expelled
• “Bloody show” exposed capillaries seep blood and mixed with mucus resulting to pink-tinged color

• Sudden gush or a scanty, slow seeping of clear fluid from the vagina
• Early rupture is advantageous if it causes the fetal head to settle snugly into the pelvis, resulting to short labor

• Pelvic Shape: Gynecoid 
• True Pelvis: The bony passageway through which the fetus must pass during delivery 
• Obstetric/True Conjugate: The most important measurement of the inlet because it has the smallest diameter (at least N-11 cm)
• For the pelvic outlet (below the ischial spine), AP > T, transverse is measured
• Measurement is the ischial tuberosity = at least 10 cm 

• Most Important: Bony Pelvic Ring 
• AP: 9.5 cm ; Transverse: 9.25 
• Fontanelle spaces compress during birth to aid in molding of the fetal head