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NRSG 206: OB > [Exam 2] Chapter 23 – Nursing Management of the Newborn with Special Needs > Flashcards

[Exam 2] Chapter 23 – Nursing Management of the Newborn with Special Needs Flashcards

1
Q

Birthweight Vairations: Description of appropriate for gestational age (AGA)?

A

Newborn with weight that falls within 80% of all births. Have lower morbidity and mortality than other groups

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2
Q

Birthweight Vairations: Description for small for gestation age? (SGA)

A

Weigh less than 2500 g (5 lb 8 oz). Or if birthweight is below teh 10th percentile correlated to their gestational age

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3
Q

Birthweight Vairations: Description for large for gestational age?

A

Those who weight more than 4000 g (8 lb and 13 oz) due to accelerated overgrowth for length of gestation

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4
Q

Birthweight Vairations: Weight for low birthweight?

A

Less than 2500 g (5.5 lb)

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5
Q

Birthweight Vairations: Weight for very low birthweight?

A

Less than 1500 g (3 lb 5 oz)

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6
Q

Birthweight Vairations: Weight for extremely low birthweight?

A

Less than 1000 g (2lb 3 oz)

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7
Q

SGA Newborns: Those with fetal growth restriction are considered at risk for what

A

increased morbidity and mortality rates

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8
Q

SGA Newborns: What does symmetric FGR refer to?

A

Fetuses with equally poor growth rates of the brain, abdomen, and long bones and thought to result from early global insult

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9
Q

SGA Newborns: What is asymmetric FGR refer to?

A

Infants whose brain growth is spared comapred to their abdomen and internal organs

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10
Q

SGA Newborns and Nursing Assessment: Begins by reviewing for risk factors such as waht

A

smoking, drug abuse, alcohol consumption, preeclampsia, anemia, and intrauterine viral infection

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11
Q

SGA Newborns and Nursing Assessment: Observe for typical characteristics at birth such as?

A

Head disproportionately large compared to rest of body

Wasted appearance of extremities

Jittery

Temperature instability

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12
Q

SGA Newborns and Nursing Assessment: Maternal causes of this?

A

Chronic hypertension, soking, low socioeconomic status, abuse, preeclampsia

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13
Q

SGA Newborns and Nursing Assessment: Placental factors of this?

A

Abnormal cord insertion , placenta previa, decreased placental weight

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14
Q

SGA Newborns and Nursing Mx: Interventions for this may include what?

A

Obtaining weight, length, and head circumference, and comparing them to standards

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15
Q

SGA Newborns and Nursing Mx: What is Polycythemia?

A

Venous hematocrit above 65% and hemoglobin of more than 20 grams. Peaks between 6-12 hours of age.

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16
Q

SGA Newborns and Nursing Mx - Polycythemia: What does hyperviscosity of the blood lead to?

A

Increased reistance of blood flow an decreased oxygen delivery. Can cause abnormalities of central nervous sytem , hypoglycemia, and decreased renal function

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17
Q

SGA Newborns and Nursing Mx - Polycythemia: When should screenings occur?

A

Mothers who are diabetic put at risk. Screening at 2, 12 , and 24 hours of age

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18
Q

SGA Newborns and Nursing Mx - Polycythemia: What are some clinical signs of polycyhemia?

A

Respiratory distres, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy

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19
Q

SGA Newborns and Nursing Mx - Polycythemia: What will asymptomatic newborns with hematocrit between 65-70 be prescribed?

A

Fluids, close observation, and a repeat hematocrit level in 12 hours

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20
Q

SGA Newborns and Nursing Mx - Polycythemia: Tx if newborn is symptomatic?

A

Partial exchange transfusion with replacement of removed red blood cell volume with volume expanders.

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21
Q

LGA Newborns, Nursing Assessment: Maternal factors that increase risk of having this type of infant include what

A

diabetes/glucose intolerance, multiparity, prior hx of a macrosomic infant, postterm gestation, maternal obesity, and gestational weight gain

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22
Q

LGA Newborns, Nursing Assessment: How will they appear?

A

Large body and appears plump and full-faced. Have poor motor skills and difficulty regulating behavioral states

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23
Q

LGA Newborns, Nursing Assessment: Assess for traumatic injuries such as?

A

Fractured clavicles, brachial palsy, facial paralysis, phrenic nerve palsy, skull fractures, or hematoma

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24
Q

LGA Newborns, Nursing Assessment: Why are they at risk for hypoglycemia?

A

Due to early depletion of glycogen stores in their liver. Obtain frequent glucose levels.

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25
Q

LGA Newborns, Nursing Assessment: Clinical signs of hypoglycemia?

A

Lethargy, drowsiness, tachypnea, weak cry, jitteriness, seizures, bradycardia

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26
Q

LGA Newborns, Nursing Mx - Hypoglycemia: What level is this at?

A

Below 40 mg/DL

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27
Q

LGA Newborns, Nursing Mx - Hypoglycemia: Associated with variety of neonatal conditions like what

A

prematurity, FGR, and maternal diabetes

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28
Q

LGA Newborns, Nursing Mx - Hypoglycemia: Initial tx option in asymptomatic hypoglycemia?

A

Supervisied breast-feeding or formula

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29
Q

LGA Newborns, Nursing Mx - Hypoglycemia: How should symptomatic hypoglycemia be treated?

A

Continuous infusion of parenteral dextrose. Need at rate above 12 mg/kg/min

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30
Q

LGA Newborns, Nursing Mx - Hypoglycemia: When should you assess glucose levels?

A

Within 30 mins of birth adn repeat the screening every hour

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31
Q

LGA Newborns, Nursing Mx: Polycythemia and hyperviscosity are associated with what problems?

A

fine and gross motor delays, speech delays, and neurologic sequelae

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32
Q

Gestational Age Variations: Mean age of pregnancy?

A

280 days or 40 weeks.

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33
Q

Gestational Age Variations: When is a preterm newborn born?

A

Before 37 weeks

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34
Q

Gestational Age Variations: When is a postterm infant born?

A

After 42 weeks

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35
Q

Gestational Age Variations: When is a late preterm infant born?

A

BEtween 34 to 36 weeks

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36
Q

Posterm Newborn: What happens to the placenta after 42 weeks?

A

Ability to provide adequate oxygen and nutrients compromised. Placenta begins aging . Begins to use its own resources and begins to waste away

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37
Q

Posterm Newborn - Nursing Assessment: Nursing care activites include what

A

asseessing neonate complication, assessing for birth trauma, maintaining body tem,p, and offering emotional support

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38
Q

Posterm Newborn - Nursing Assessment: What characteristics do they often exhibit?

A

Dry, cracked, peeling skin

Long, thin extremities

Wide-eyed, alert expression

Abundant hair on scalp

Long fingernails

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39
Q

Posterm Newborn - Nursing Assessment: What to do with meconium?

A

Observe for meconium-stained umbilical cord and fingernails to assess for meconium aspiration

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40
Q

Posterm Newborn - Nursing Assessment: What other typical complications can be associated here?

A

Perinatal asphyxia, hypoglycemia, hypothermia, and polycythemia

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41
Q

Posterm Newborn - Nursing Mx: At high risk for perinatal asphyxia, which is attributed to?

A

Placental deprivation or eligohydramnios that leads to cord compression, thereby reducing perfusion to the fetus

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42
Q

Posterm Newborn - Nursing Mx: What can help stabilize blood glucose levels?

A

Give them intravenous dextrose 20% or initiate early feedings to help stabilize the blood glucose levels

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43
Q

Posterm Newborn - Nursing Mx: What will you observe of the infant?

A

Skin temp, respiration characteristics, results of blood studies, like aBGs and serum bilirubin levels

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44
Q

Posterm Newborn - Nursing Mx: How do you treat polycythemia?

A

This leads to hyperbilirubinemia due to rbc destruction. Providing adequate hydration helps reduce the viscosity of the newborns blood

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45
Q

Preterm Newborn: Continue to be at high risk for neurodevelopmental disorders such as

A

cerebral palsy or mental retardation, intraventricular hemorrhage, congenital anomalies, and behavioral problems

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46
Q

Preterm Newborn: Most common complications seen here?

A

Respiratory distress syndrome, hemorrhage, retinopathy, anemia, and hypoglycemia

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47
Q

Preterm Newborn - Effects on Body System, Resp. System: How is this developmental wise?

A

One of the last body systems to mature. Greatest risk for resp complications

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48
Q

Preterm Newborn - Effects on Body System, Resp. System: When problems here affect the newborns breathing?

A

Surfactant deficiency.

Unstable chest wall, leading to atelectasis

Immature respiratory control centers

Smaller respiratory passages

Inability to clear fluid from passages

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49
Q

Preterm Newborn - Effects on Body System, Cardiovascular System: What problems persist here?

A

If oxygen remains low, fetal pattern of circulation by persist causing blood flow to bypass the lungs.

There is also a patent ductus arteriosus and open foramen ovale

50
Q

Preterm Newborn - Effects on Body System, GI System: Lack the neuromuscular coordination required dot maintain what?

A

The suck, swallowing, and breathing regimen necessary for sufficient calorie and fluid intake to support growth.

51
Q

Preterm Newborn - Effects on Body System, GI System: What does perinatal hypoxia cause?

A

Shunting of blood from the gut to more important organs such as the heart and brain. . Places at risk for malnutrition and weight loss

52
Q

Preterm Newborn - Effects on Body System, GI System: What is not properly developed here”?

A

Small stomach capacity, weak abdominal muscles, compromised metabolic function, and limited ability to digest proteins.

53
Q

Preterm Newborn - Effects on Body System, GI System: How are feedings down here?

A

Through enteral or intravenous feedings

54
Q

Preterm Newborn - Effects on Body System, GI System: What is the rate for enteral feedings?

A

Usually 0.5 - 1 mL / kg/ h to induce surges of gut hormones that enhance maturation of the intestine

55
Q

Preterm Newborn - Effects on Body System, Renal System: What are they not able to do?

A

Reduced ability to concentrate urine and slowing the glomerular filtration rate. Fluid retention and electorlyte disturbances may occur. Can also not clear drugs as easily.

56
Q

Preterm Newborn - Effects on Body System, Immune System: Deficency in IgG may occur why?

A

Because transplacental transfer does not occur until after 35 weeks.

57
Q

Preterm Newborn - Effects on Body System, Immune System: Main problems here?

A

Cannot create antibodies. Also newborns thin skin and fragile blood vessels provide a limited protective barrier

58
Q

Preterm Newborn - Effects on Body System, CNS: Main risks here?/

A

Difficulty regulating temperature. Due to lack of fat. Crucial to prevent cold stress.

59
Q

Preterm Newborn - Nursing Assessment: Common physical characteristics incldue what?

A

Birthweight less than 5.5 lb.

Scawny Appearance

Poor muscle tone and flexion

Minimal subcutaneous fat.

Plentiful Lanugo

Fused Eyelids

Soft and spongy skull bones

60
Q

Preterm Newborn - Nursing Assessment: Maternal risk factors associated with this include what?

A

Previous preterm delivery, low socioeconomic status, preeclampsia, hypertension, poor maternal nutrition, smoking

61
Q

Preterm Newborn - Nursing Assessment: What assessments will be done?

A

VS, temperature, heart rate. And monitor respiratory effort, especially peeriods of apnea lasting longer than 20 seconds

62
Q

Preterm Newborn - Nursing Assessment: What will you monitor for with polycythemia?

A

Hemoglobin and hematocrit

63
Q

Preterm Newborn - Nursing Assessment: Observe for nonspecific signs of hypoglycemia such as ?

A

Lethargy, poor feeding, and seizures

64
Q

Preterm Newborn - Nursing Mx, Promoting Oxygenation: The work in taking the first breath is due to what?

A

Overcomiing the surface tension of the walls of the terminal lung units at the gas tissue interface

65
Q

Preterm Newborn - Nursing Mx, Promoting Oxygenation: Newborns may have asphyxia , which is what?

A

Who fails to establish a adequate respiration after birth. They are deprived of oxygen during nursing process, resulting in fetal hypoxia that leads to brain damage

66
Q

Preterm Newborn - Nursing Mx, Promoting Oxygenation: Why is surfactant important?

A

Lowers surface tension in alveoli and stabilizes them to prevent their collapse

67
Q

Preterm Newborn - Nursing Mx, Promoting Oxygenation: Inability to initiate and establish respirations leads to what?

A

Hypoxemia and hypoxia, acidosis , and hypercarbia (increased carbon dioxide)

68
Q

Preterm Newborn - Nursing Mx, Promoting Oxygenation: What happens if newborn has hypoxia?

A

Heart rate falls, cyanosis develops, temperature decreases, blood pressure decreases and respirations altered.

69
Q

Preterm Newborn - Nursing Mx, Resucitating Newborn: What steps should be done if newborn not breathing properly?

A

Stabilziation , dry newborn, provide wwarmth, and clear airway with bulb

Assess for breathing

Pulse OX

Ventilation

Assess HR

Chest compressions

Administer epinephrine

70
Q

Preterm Newborn - Nursing Mx, Resucitating Newborn: What considerations must be taken of the newborn when performing resuscitation?

A

Have immature blood vessels in brain prone to hemorrhage, thin skin which means rapid heat loss, increased susceptibilty to infection, increased risk of hypovolemic shock

71
Q

Preterm Newborn - Nursing Mx, Resucitating Newborn: What is the ABCD mnemonic that should be remebered?

A

Airway, breathing, circulation, and drugs

72
Q

Preterm Newborn - Nursing Mx, Resucitating Newborn: Measured are done until what happens?

A

Pulse above 100 bpm, good healthy cry, and pink tongue.

73
Q

Preterm Newborn - Nursing Mx, Administer Oxygen: What to know for oxygen?

A

Oxygen should be used judiciously to prevent development of further complications.

74
Q

Preterm Newborn - Nursing Mx, Administer Oxygen: Common practice for oxygen?

A

Maintain oxygen saturation levels in the high 80s to mid 90s

75
Q

Preterm Newborn - Nursing Mx, Administer Oxygen: Respiratory distress in commonly caused by

A

deficiency of surfactant, retained fluid in lungs, meconium aspiration, pneumoniam hypothermia or anemia

76
Q

Preterm Newborn - Nursing Mx, Administer Oxygen: Princples of care for newborn here?

A

Keep newborn warm

Handle newborn as little as possible

Provide energy through calories.

Tx cyanosis with oxygen hood.

REcord observations eveyry hour

77
Q

Preterm Newborn - Nursing Mx, Maintaining Thermal Regulation: How does infant attempt to conserve body heat?

A

By vasoconstriction and thermogenesis by metabolizing brown adipose tissue and increasing oxygen consumption

78
Q

Preterm Newborn - Nursing Mx, Maintaining Thermal Regulation: How will an infant appear that is having problems with thermal regulation?

A

Cool to cold to the touch. Hands, fet, and tongue may appear cyanotic. Respirations are shallow

79
Q

Preterm Newborn - Nursing Mx, Maintaining Thermal Regulation: What to know when promoting thermal regulation for preterm newborn?

A

Remmeber four mechanisms of heat treansfer

Frequencya ssess temperature

Utilize plastic wraps and bags

Assess newborns temperature every hour.

Observe for clinical signs of cold stress and respiratory distress, centreal cyanosis, and hypoglycemia.

80
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Fluid Balance: How can they receive nutrition?

A

Orally, enterally, or parenterally via infusion

81
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Fluid Balance: Why are gavage feedings used?

A

For compromised newborns to allow them to rest during the feeding process. Many may have a weak suck

82
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Fluid Balance: How do newborns born after 34 weeks feed?

83
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Fluid Balance: How do those born before 34 weeks feed?

A

with parenteral nutrition within the first 24 hours of life.

84
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Fluid Balance: How can you promote nutrition and fluid balance in preterm newborn?

A

Measure daily weight

Monitor intake

Assess fluid status by monitoring weight, urinary output, urine SpG

Continually assess for enteral feeding intolerance, measure abdominal girth, and auscultate bowel sounds

Encourage and support breast feeding

85
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Preventing Infection: sources of infection Can be divided into what three categories?

A

TRansplacental Acquisition (Intrauterine Infection)

Perinaal Acquisition during Childbirth (intrapartum infection

Hospitall acquisition in neonatal period (postnanal infection)

86
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Preventing Infection: Why are they at risk for infection?

A

They have not developed antibodies needed for passive protection

87
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Preventing Infection: Clinical manifestations may include?

A

Apnea, diminished activity, poor feeding, temperature instability, respiratory distress, seizures, tachycardia, hypotonia, and pallor, jaundice

88
Q

Preterm Newborn - Nursing Mx, Promoting Nutrition and Preventing Infection: What interventions can be done to prevent infection?

A

Assess for risk factors in maternal hx.

Monitor for changes in VS

Assess Oxygen

Assess Feeding tolerance

Monitor lab test results

Avoiding using tape on newborn sskin

Use sterile gloves when assissting with procedure

89
Q

Preterm Newborn - Nursing Mx, Providing Appropriate Stimulation: What cn be done to help newborn progress in feeding abilities more quickly?

A

Rocking, pacifier, skin-to-skin contact with parents, containment, music, nonnutritive sucking, breas-feeding

90
Q

Preterm Newborn - Nursing Mx, Providing Appropriate Stimulation: Overstimulation can have what negative effects?

A

Reducing oxygenation and causing stress

91
Q

Preterm Newborn - Nursing Mx, Providing Appropriate Stimulation: How do they react to stress?

A

By flaying the hands or bringing an arm up to cover the face. RR, HR may bdecrease and periods of apea or bradydcardia may follow

92
Q

Preterm Newborn - Nursing Mx, Providing Appropriate Stimulation: Appropriate developmental stimulation would include what?

A

Kangaroo holding, rocking, soft singing or music, cuddling, or gentle stroking of infants skin

93
Q

Preterm Newborn - Nursing Mx, Managing Pain: What can be done for comfort during painful procedure?

A

Appropriate sized pacifier.

Administration of oral sucrose with and without nonnutritive sucking.

94
Q

Preterm Newborn - Nursing Mx, Managing Pain: What does the Premature Infant Pain Profile (PIPP) assess?

A

Heart rate and oxygen saturation

95
Q

Preterm Newborn - Nursing Mx, Managing Pain: What does the CRIES tool lnclude?

A

Cry, Requires Oxygen, Increased VS, Expression, And Sleeplessness

96
Q

Preterm Newborn - Nursing Mx, Managing Pain: What is the NIPS scale?

A

Neonatal Infant Pain Scale, which evalutes respiratory patterns

97
Q

Preterm Newborn - Nursing Mx, Managing Pain: Suspect pain if newborn exhibits what?

A

Sudden, high-pitched cry. Facial grimace. Increased muscle tone. Oxygen desaturation. Increased HR, Body Posturing. Limb Withdrawal

98
Q

Preterm Newborn - Nursing Mx, Managing Pain: Effective pain management strategies for newborns include?

A

Preventing, limiting, or avoidign noxious stimuli

Using nonpharm techniques to reduce pain

Administer pharamcologic agents when appropriate

99
Q

Preterm Newborn - Nursing Mx, Managing Pain: Nonpharm pain management strats include?

A

Nonnutritive sucking, breast-feeding, radiant heat to promote warmth, skin-to-skin contact, and sweetened solutions

100
Q

Preterm Newborn - Nursing Mx, Managing Pain: Pharm strats may include what?

A

Narcotic analgesics, but they are limited. Morphine and FEntanyl usually administered IV.

ACetaminophen for mild pain

Benzos used as ssedatives

101
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: Developmentally supporitve care is defined as?

A

Care of a newborn or infant to support positive growth and development.

102
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: Developmental care focuses on what?

A

What newborns or infants can do at that stage of development.

103
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: What strats are included in developmental care?

A

Clustering care to promote rest and conserve infants energy

Flexed positioning to stimulate in utero positioning

Environmental management to reduce noise

Kangaroo care to promote skin-to-skin

104
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: What activites promote self-regulation and state regulation?

A

Surrounding newborn with nesting rolls/devices

Swaddling blanket to maintain flexed positon

Providing sheepskin or waterbed to stimulate uterine environment

Providing nonnutritive sucking

105
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: How can developmental car e be clustered?

A

Cluserting lights in one area, installing visual alarm systems, and limiting overhead pages to minimize noise

106
Q

Preterm Newborn - Nursing Mx, Promoting Growth and Development: What is the ideal enviroment for newborns development?

A

Dim the lights and cover isoletes at night

Support ealy extubation from mechanical ventilation

Encourage early and consistent feedings with breast milk

Adminsiter prescribed antibiotics

Positio newborn as if she was still in utero

107
Q

Preterm Newborn - Nursing Mx, Promoting Parental Coping: What interventions can be done to reduce parental anxiety?

A

Reviewing what occured since birth

Provide individualized support while in NICU

Providing simple relaxation and calming techniques

Exploring their perception of newborns condition

Validating their anxiety as normal

Encourage frequent visits to NICU

108
Q

Preterm Newborn - Nursing Mx, Preparing for Discharge: When is this process started?

A

With evidence that recovery of newborn is certain. Goal of discharge plan is to make a successful transition to home care.

109
Q

Preterm Newborn - Nursing Mx, Preparing for Discharge: When planning for discahrge of high-risk infant, nurse should include what?

A

Assess physical status of mother

Discuss early signs of complicatiosn adn waht to do

Stress importance of proper car seat use

Reinforce instructions for equipment

Provide breast-feeding support

110
Q

Preterm Newborn - Nursing Mx, Preparing for Discharge: Infants born at what weeks are at the highest risk for morbidity and mortality?

A

Those born beetween 34 weeks and 37 weks

111
Q

Late Preterm Newborn: When is this infant born?

A

Between 34 weeks and 36 6/7 weeks of gestation.

112
Q

Late Preterm Newborn: Most common complicatiosn from here are what?

A

Cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia and feeding difficulties

113
Q

Late Preterm Newborn: What challenges face this group?

A 
Respiratory didstress
Thermoregulation Issues
Hypoglycemia
Apnea
Jaundice and hyperbilirubinemia
Feeding Challenges
Sepsis
114
Q

The nurse documents that a newborn is postterm based on the understanding that he was born after:

38 weeks’ gestation
40 weeks’ gestation
42 weeks’ gestation
44 weeks’ gestation
115
Q

SGA and LGA newborns have an excessive number of red blood cells related to:

Hypoxia
Hypoglycemia
Hypocalcemia
Hypothermia
116
Q

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following?

Hyperbilirubinemia
Hypothermia
Polycythemia
Hypoglycemia
A

Hypothermia

117
Q

In assessing a preterm newborn, which of the following findings would be of greatest concern?

Milia over the bridge of the nose
Thin transparent skin
Poor muscle tone
Heart murmur
A

Heart murmur

118
Q

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate?

Sheltering the parents from the bad news
Making all the decisions regarding care
Encouraging them to participate in the newborn’s care
Leaving them by themselves to allow time to grieve
A

Encouraging them to participate in the newborn’s care

119
Q

The nurse is providing care to several newborns with variations in gestational age and birthweight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply.

Keeping the handling of the newborn to a minimum
Maintaining a neutral thermal environment
Decreasing environmental stimuli
Initiating early oral feedings
Using thermal warmers in all cribs
120
Q

Which of the following concepts would the nurse incorporate into the plan of care when assessing pain in a newborn with special needs?

Newborns experience pain primarily with surgical procedures.
Preterm newborns in the NICU are at least risk for pain.
Pain assessment needs to be comprehensive and frequent.
A newborn’s facial expression is the primary indicator of pain.
A

Pain assessment needs to be comprehensive and frequent.

121
Q

Evidence-based practice refers to the use of which of the following to validate your practice?

Research findings
Written guidelines
Traditional practices
Institutional policies
A

Research Findings

NRSG 206: OB (42 decks)

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