PRENATAL PERIOD PYRAMID POINTS Physical assessment findings in

PRENATAL PERIOD

PYRAMID POINTS • • Physical assessment findings in the prenatal period Physiological changes that occur during pregnancy Client education regarding prenatal visits Client education regarding interventions related to the discomforts that occur during pregnancy, and the measures to prevent the discomforts • Interventions related to the performance of diagnostic tests and procedures • Client education regarding nutrition during pregnancy

PHYSIOLOGICAL MATERNAL CHANGES • CARDIOVASCULAR SYSTEM – Circulating blood volume increases, plasma increases, total volume increases by 40 to 50% – Physiological anemia occurs as the plasma increase exceeds the increase in red blood cell (RBC) production – Heart size increases with left ventricle hypertrophy and the heart is elevated upward and to the left due to displacement of the diaphragm as the uterus enlarges

PHYSIOLOGICAL MATERNAL CHANGES • CARDIOVASCULAR SYSTEM – Pulse may increase about 10 beats per minute – Blood pressure may decline in the second trimester – Iron requirements are increased – Retention of sodium and water may occur

PHYSIOLOGICAL MATERNAL CHANGES • RESPIRATORY SYSTEM – Oxygen consumption increases by 15 to 20% – Diaphragm is elevated due to the enlarged uterus – Respiratory rate remains unchanged – Shortness of breath may be experienced

PHYSIOLOGICAL MATERNAL CHANGES • GASTROINTESTINAL (GI) SYSTEM – Nausea and vomiting may occur due to the secretion of human chorionic gonadotropin (h. CG), and subsides by the third month – Poor appetite may occur due to the decreased gastric motility – Alterations in taste and smell may occur – Constipation may occur due to decreased GI motility or pressure of the uterus

PHYSIOLOGICAL MATERNAL CHANGES • GASTROINTESTINAL SYSTEM – Flatulence and heartburn may occur due to decreased GI motility and slow emptying of the stomach – Hemorrhoids may occur due to increased venous pressure – Gum tissue may become swollen and easily bleed – Ptyalism (excessive secretion of saliva)

PHYSIOLOGICAL MATERNAL CHANGES • RENAL SYSTEM – Frequency of urination occurs in the first and third trimester due to pressure of the enlarging uterus on the bladder – Decreased bladder tone is caused by hormonal changes – Decreased bladder capacity results – Renal function increases – Renal threshold for glucose may be reduced

PHYSIOLOGICAL MATERNAL CHANGES • ENDOCRINE SYSTEM – Basal metabolic rate rises – Anterior lobe of the pituitary gland enlarges – Thyroid enlarges slightly, and thyroid activity increases – Aldosterone levels gradually increase – Parathyroids increase in size

PHYSIOLOGICAL MATERNAL CHANGES • UTERUS – Enlarges from a weight of 60 g to a weight of 1000 g – Size and number of blood vessels and lymphatics increase – Irregular contractions occur

PHYSIOLOGICAL MATERNAL CHANGES • CERVIX – Becomes shorter, more elastic, and larger in diameter – Endocervical glands secrete a thick mucus plug, which is expelled from the canal when dilation begins – Increased vascularization causes a softening and blue-purple discoloration known as Chadwick’s sign and occurs at approximately 6 weeks of gestational age

CERVICAL CHANGES From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

PHYSIOLOGICAL MATERNAL CHANGES • OVARIES – The maturation of new follicles is blocked – The ovaries cease ovum production

PHYSIOLOGICAL MATERNAL CHANGES • VAGINA – Hypertrophy and thickening of the muscle occurs – An increase in vaginal secretions occurs, and secretions are usually thick, white, and acidic

PHYSIOLOGICAL MATERNAL CHANGES • BREASTS – Breast size increases – Nipples become more pronounced – Areola becomes darker in color – Superficial veins become prominent – Hypertrophy of Montgomery’s follicles occurs – Colostrum may appear from the breast

BREAST CHANGES From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

PHYSIOLOGICAL MATERNAL CHANGES • SKIN – Pigmentation increases – A dark streak down the midline of the abdomen may appear (linea nigra) – Chloasma, or mask of pregnancy, may occur over the forehead, cheeks, and nose – Reddish-purple stretch marks (striae) may occur on the abdomen, breasts, thighs, and upper arms – Vascular spider nevi may occur on the neck, chest, face, arms, and legs – Rate of hair growth may decrease

SKIN CHANGES From Murray, S. , Mc. Kinney, E. , and Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

PHYSIOLOGICAL MATERNAL CHANGES • SKELETAL SYSTEM – Center of gravity changes – Postural changes occur as the increased weight of the uterus causes a forward pull of the bony pelvis

PHYSIOLOGICAL MATERNAL CHANGES • METABOLISM – Metabolic function increases – Body weight increases – The average expected weight gain during pregnancy is 2 to 4 pounds in the first trimester, and approximately 1 pound per week in the second and third trimesters – Water retention is increased, which can contribute to weight gain

PSYCHOLOGICAL MATERNAL CHANGES • AMBIVALENCE – Occurs early in pregnancy, even when the pregnancy is planned – Mother may experience dependentindependence conflict and ambivalence related to role changes – Father may experience ambivalence related to the new role he is assuming, the increased financial responsibilities, and sharing the mother’s attention with the child

PSYCHOLOGICAL MATERNAL CHANGES • ACCEPTANCE – Factors that may be related to acceptance of the pregnancy are the woman’s readiness for the experience and her identification with the motherhood role

PSYCHOLOGICAL MATERNAL CHANGES • EMOTIONAL LABILITY – May be manifested by frequency in the change of emotional states or extremes in emotional states – These emotional changes are common, and the mother may feel that these changes are abnormal

PSYCHOLOGICAL MATERNAL CHANGES • BODY IMAGE CHANGES – The changes in a woman’s perception of her image during pregnancy occurs gradually and may be either positive or negative – The physical changes and symptoms that the woman experiences during pregnancy contribute to her body image

DISCOMFORTS OF PREGNANCY • • • Nausea and vomiting Syncope Urinary urgency and frequency Breast tenderness Increased vaginal discharge Nasal stuffiness Fatigue Heartburn Ankle edema

DISCOMFORTS OF PREGNANCY • • Varicose veins Headaches Hemorrhoids Constipation Backache Leg cramps Shortness of breath

NAUSEA AND VOMITING • DESCRIPTION – Occur in the first trimester – Due to elevated h. CG levels and changes in carbohydrate metabolism • CLIENT EDUCATION – Eat dry crackers before arising – Eat small, frequent, low-fat meals during the day – Drink liquids between meals – Avoid fried foods – Avoid all antiemetics throughout pregnancy

SYNCOPE • DESCRIPTION – Usually occurs in the first trimester – May be hormonally triggered or caused by the increased blood volume, anemia, fatigue, or sudden position changes • CLIENT EDUCATION – Sit with the feet elevated – Change positions slowly – Change the position to the left side to relieve the pressure of the uterus on the inferior vena cava

URINARY URGENCY AND FREQUENCY • DESCRIPTION – Usually occurs in the first and third trimesters – Due to pressure of the uterus on the bladder • CLIENT EDUCATION – Drink 2 quarts of fluid per day – Limit fluid intake in the evening – Void at regular intervals – Sleep on the side at night – Wear perineal pads if necessary

BREAST TENDERNESS • DESCRIPTION – Can occur from the first through the third trimesters – Due to increased levels of estrogen and progesterone • CLIENT EDUCATION – Encourage the use of a supportive bra with nonelastic straps – Avoid the use of soap on the nipples and areola area to prevent drying

INCREASED VAGINAL DISCHARGE • DESCRIPTION – Can occur from the first through the third trimesters – Due to hyperplasia of vaginal mucosa and increased mucus production • CLIENT EDUCATION – Proper cleansing and hygiene – Wear cotton underwear – Avoid douching – Advise the client to consult the physician or health care provider if infection is suspected

NASAL STUFFINESS • DESCRIPTION – Occurs during the first through the third trimesters – Occurs due to increased estrogen that causes swelling of the nasal tissues and dryness • CLIENT EDUCATION – Encourage the use of a humidifier – Avoid the use of nasal sprays or antihistamines

FATIGUE • DESCRIPTION – Occurs usually in the first and third trimesters – Usually a result of hormonal changes • CLIENT EDUCATION – Arrange frequent rest periods throughout the day – Exercise regularly – Avoid eating and drinking foods containing stimulants throughout pregnancy

HEARTBURN • DESCRIPTION – Occurs in the second and third trimesters – Results from increased progesterone levels, decreased GI motility and esophageal reflux, and displacement of the stomach by the enlarging uterus • CLIENT EDUCATION – Eat small, frequent meals and sit upright for 30 minutes following a meal – Avoid fatty and spicy foods and drink milk between meals – Perform tailor reach exercise to expand the thoracic space

TAILOR REACH EXERCISE From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and practice. Philadelphia: W. B. Saunders.

ANKLE EDEMA • DESCRIPTION – Usually occurs in the second and third trimesters – Occurs due to vasodilation, venous stasis, and increased venous pressure below the uterus • CLIENT EDUCATION – Elevate the legs at least twice a day – Sleep on the left side – Wear supportive stockings – Avoid sitting or standing in one position for long periods of time

VARICOSE VEINS • DESCRIPTION – Usually occur in the second and third trimesters – Occur due to weakening walls of the veins or valves and venous congestion • CLIENT EDUCATION – Wear support hose – Elevate the feet when sitting, and the feet and hips when lying down – Avoid long periods of standing or sitting – Avoid pressure on the lower thighs, leg crossing, or wearing constricting clothing

HEADACHES • DESCRIPTION – Usually occur in the second and the third trimesters – Occur due to changes in blood volume and vascular tone • CLIENT EDUCATION – Change positions slowly – Apply a cool cloth to the forehead – Eat a small snack – Use acetaminophen (Tylenol) sparingly only if prescribed by the physician or health care provider

HEMORRHOIDS • DESCRIPTION – Usually occur in the second and third trimesters – Occur due to increased venous pressure and/or constipation • CLIENT EDUCATION – Soak in a warm sitz bath – Sit on a soft pillow – Eat high-fiber foods and drink sufficient fluids – Increase exercise, such as walking – Apply ointments, suppositories, or compresses as prescribed

CONSTIPATION • DESCRIPTION – Usually occurs in the second and third trimesters – Occurs due to decreased intestinal motility, displacement of the intestines, and taking iron supplements • CLIENT EDUCATION – Eat high-fiber foods – Drink plenty of fluids – Exercise regularly

BACKACHE • DESCRIPTION – Usually occurs in the second and third trimesters – Occurs from an exaggerated lumbosacral curve due to the enlarged uterus • CLIENT EDUCATION – Encourage rest periods – Use good body mechanics and improve posture – Wear low-heeled shoes – Perform exercises to prevent backache – Sleep on a firm mattress

EXERCISES TO PREVENT BACKACHE From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

LEG CRAMPS • DESCRIPTION – Usually occur in the second and third trimesters – Occur as a result of an altered calciumphosphorus balance and pressure of the uterus on nerves, or from fatigue • CLIENT EDUCATION – Get regular exercise, especially walking – Elevate the feet and dorsiflex the feet when resting – Increase calcium intake – Stretch the affected muscle to relieve the leg cramps

MUSCLE STRETCHING TO RELIEVE LEG CRAMPS From Nichols, F. & Zwelling, E. (1997). Maternal newborn nursing: Theory and practice. Philadelphia: W. B. Saunders.

SHORTNESS OF BREATH • DESCRIPTION – Can occur in the second and third trimesters – Occurs due to pressure on the diaphragm • CLIENT EDUCATION – Allow frequent rest periods – Sleep with the head elevated or on the side – Avoid overexertion

PRENATAL VISITS • Every 4 weeks first for 28 to 32 weeks • Every 2 weeks from 32 to 36 weeks • Every week from 36 to 40 weeks

BLOOD TYPE AND RH FACTOR • ABO typing is performed to determine the woman’s blood type • Rh typing is done to determine the presence or absence of Rh antigen (Rh-positive or Rhnegative) • If the client is Rh negative and has a negative antibody screen, the client will need repeat antibody screens and should receive Rh immune globulin at 28 weeks gestation

RUBELLA TITER • If the client has a negative titer, indicating susceptibility to the rubella virus, the client should receive the appropriate immunization postpartum • The client must be using effective birth control at the time of the immunization and counseled not to become pregnant for 3 months following immunization

HEMOGLOBIN AND HEMATOCRIT LEVELS • Hemoglobin and hematocrit levels will drop during gestation as a result of increased plasma volume • An increase in the hematocrit level may indicate the development of pregnancy-induced hypertension (PIH) • A decrease in the hemoglobin level below 10 g/dl or in the hematocrit level below 30 g/dl indicates anemia

PAPANICOLAOU SMEAR • Done during the initial prenatal examination • Screens for cervical neoplasia

GONORRHEA CULTURE • Done during the initial prenatal examination to screen for gonorrhea • May be repeated during the third trimester in high -risk clients

SYPHILIS SCREENING • Done during the initial prenatal examination to screen for syphilis • May be repeated during the third trimester in high -risk clients

HERPES CULTURES • Indicated for clients with a positive history or those with active lesions • Performed to determine the route of delivery • Weekly cultures may be done at the 35 th or 36 th week of pregnancy until delivery

CHLAMYDIA CULTURE • Indicated if the client is in a high-risk group • Indicated if infants from previous pregnancies have developed neonatal conjunctivitis or pneumonia

SICKLE CELL SCREENING • Indicated for clients at risk for sickle cell disease • A positive test may indicate a need for further screening

TUBERCULIN SKIN TEST • The health care provider may prefer to perform this skin test after delivery • A positive skin test indicates the need for chest radiograph (using an abdominal lead shield) to rule out active disease • In a pregnant client, chest radiograph will not be performed until after 20 weeks of gestation (after fetal organs are formed) • Converters to positive may be referred for treatment with medication following delivery

HEPATITIS B SURFACE ANTIGENS • Recommended for all women because of the prevalence of the disease in the general population

URINALYSIS AND URINE CULTURE • A urine specimen for glucose and protein determinations should be obtained at every prenatal visit • Glycosuria is a common result of decreased renal threshold that occurs during pregnancy • If glycosuria persists, this may indicate diabetes • White blood cells in the urine may indicate infection • Ketonuria may result from insufficient food intake or vomiting • Levels of 2+ to 4+ protein in the urine may indicate infection or pregnancy-induced hypertension (PIH)

ULTRASONOGRAPHY • Outlines and identifies fetal and maternal structures • Assists to confirm gestational age and estimated date of delivery • May be done abdominally or transvaginally during pregnancy • If the abdominal ultrasound is being performed, the woman usually needs to have a full bladder to obtain a better image of the fetus • Inform the client that the test presents no known risks to the client or fetus

PROFILE OF FETAL FACIAL STRUCTURES From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3 rd ed. ). Philadelphia: W. B. Saunders. Courtesy Karin Buxton, Newport Beach, CA.

FETUS WITH HANDS IN FRONT OF THE FACE From Callen PW (2000). Ultrasonography in obstetrics and gynecology, Philadelphia, W. B. Saunders.

ALPHA-FETOPROTEIN SCREENING (AFP) • Assesses the quantity of fetal serum proteins; if elevated, it is associated with open neural tube and abdominal wall defects • Can detect spina bifida and Down syndrome • Explain that the level is determined by a single maternal blood sample drawn at 15 to 18 weeks gestation • If the level is elevated and the gestation is less than 18 weeks, a second sample is drawn • An ultrasound is performed for elevated levels to rule out fetal abnormalities or multiple gestation

CHORIONIC VILLUS SAMPLING (CVS) • Aspiration of a small sample of chorionic villus tissue at 8 to 12 weeks gestation, performed for the purpose of detecting genetic abnormalities • Instruct the client to drink water to fill the bladder before the procedure to aid in positioning the uterus for catheter insertion • Instruct the client to report bleeding, infection, or leakage of fluid at insertion site after the procedure • Rh-negative women may be given Rho. GAM for risks related to the procedure

CHORIONIC VILLUS SAMPLING (CVS) From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

KICK COUNTS (FETAL MOVEMENT COUNTING) • Mother sits quietly or lies down on the left side for 1 hour after meals and counts fetal kicks for 30 minutes • Instruct the client to notify the physician or health care provider if there are fewer than 3 kicks in 1 hour

AMNIOCENTESIS • DESCRIPTION – Aspiration of amniotic fluid done from 14 weeks of pregnancy and on – Performed to determine genetic disorders, the sex of the fetus, and fetal lung maturity • RISKS – Maternal hemorrhage – Infection – Rh isoimmunization – Abruptio placentae – Amniotic fluid emboli

AMNIOCENTESIS • IMPLEMENTATION – Instruct the client to empty the bladder before the procedure – Prepare the client for ultrasound, which is performed to locate the placenta – Obtain baseline vital signs and fetal heart rate (FHR), and monitor every 15 minutes – Position the client supine – Instruct the client that if chills, fever, leakage of fluid at the needle insertion site, decreased fetal movement, or uterine contractions occur, to notify the physician or health care provider

AMNIOCENTESIS From Murray, S. , Mc. Kinney, E. , & Gorrie, T. (2002). Foundations of maternal-newborn nursing, ed 3, Philadelphia: W. B. Saunders.

FERN TEST • A microscopic slide test to determine the presence of amniotic fluid leakage • Using sterile technique, a specimen is obtained from the external os of the cervix and vaginal pool • Fluid is examined on a slide under a microscope; a fernlike pattern occurring from the salts of amniotic fluid indicates the presence of amniotic fluid • The client is positioned in the dorsal lithotomy position and instructed to cough to cause the fluid to leak from the uterus if the membranes are ruptured

NITRAZINE TEST • Use of a Nitrazine test strip to detect the presence of amniotic fluid in vaginal secretions • Vaginal secretions have a p. H of 4. 5 to 5. 5 and do not affect the yellow Nitrazine strip or swab • Amniotic fluid has a p. H of 7. 0 to 7. 5 and turns the yellow Nitrazine blue • The client is positioned in the dorsal lithotomy position • The test tape is placed on the fluid and then assessed for a blue-green, blue-gray, or deep blue color, which indicates that the membranes are probably ruptured

NONSTRESS TEST (NST) • DESCRIPTION – Performed to assess placental function and oxygenation – Determines fetal well-being – Evaluates fetal heart rate (FHR) in response to fetal movement

NONSTRESS TEST (NST) • IMPLEMENTATION – External ultrasound transducer and the tocodynamometer (toco) are applied to the mother, and a tracing of at least 20 minutes’ duration is obtained so that the FHR and the uterine activity can be observed – Obtain baseline blood pressure (BP) and monitor BP frequently

NONSTRESS TEST (NST) • IMPLEMENTATION – Position mother in the left lateral position to avoid vena cava compression – The mother may be asked to press a button every time she feels fetal movement; the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response

NONSTRESS TEST (NST): RESULTS • REACTIVE NONSTRESS TEST (NORMAL/NEGATIVE) – Indicates a healthy fetus – Two or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end in association with fetal movement during a 20 minute period

NONSTRESS TEST (NST): RESULTS • NONREACTIVE NONSTRESS TEST (ABNORMAL) – No accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration for a 40 -minute observation • UNSATISFACTORY – Cannot be interpreted because of the poor quality of the FHR

NONSTRESS TEST (NST): RESULTS Adapted from Parer JT (1983). Handbook of fetal heart rate monitoring, Philadelphia: W. B. Saunders.

CONTRACTION STRESS TEST • DESCRIPTION – Assesses placental oxygenation and function – Determines fetal ability to tolerate labor and determines fetal well-being – Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions – Performed if the nonstress test is abnormal

CONTRACTION STRESS TEST • IMPLEMENTATION – The external fetal monitor is applied to the mother, and a 20 - to 30 -minute baseline strip is recorded – The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 -minute period have been achieved – Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of oxytocin are given

CONTRACTION STRESS TEST: RESULTS • NEGATIVE – Represented by no late or variable decelerations of the FHR • POSITIVE (ABNORMAL) – Represented by late or variable decelerations of the FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus

CONTRACTION STRESS TEST: RESULTS • EQUIVOCAL – Contains decelerations but with less than 50% of the contractions, or the uterine activity shows a hyperstimulated uterus • UNSATISFACTORY – Adequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation

CONTRACTION STRESS TEST: RESULTS Adapted from Parer JT (1983). Handbook of fetal heart rate monitoring, Philadelphia: W. B. Saunders

NUTRITION: GENERAL GUIDELINES • The average expected weight gain during pregnancy is 2 to 4 pounds in the first trimester, and approximately 1 pound per week in the second and third trimesters • Instruct the client to choose foods from the Food Guide Pyramid • An increase of about 300 calories per day is needed during pregnancy • A diet consisting of 2500 calories per day, depending on age, should meet the nutritional demands of pregnancy

NUTRITION: GENERAL GUIDELINES • Calorie needs are greater in the last two trimesters than in the first • An increase of about 500 calories per day is needed during lactation • Encourage a diet high in folic acid with folic acid supplements • A diet rich in folic acid is necessary for all women of childbearing age to prevent neural tube defect in the fetus during the first trimester of pregnancy

NUTRITION: GENERAL GUIDELINES • Increase calories, proteins, vitamins, calcium, and other minerals as required • Drink at least 8 to 10 (8 oz) glasses of fluid each day, of which 4 to 6 glasses are water • Sodium is not restricted unless specifically prescribed by the physician or health care provider

VEGETARIANISM • During pregnancy, it is necessary to obtain ample and complete proteins from dairy products and eggs • An adequate pure vegetarian diet contains protein from unrefined grains such as brown rice and whole wheat; legumes such as beans, split peas, and lentils; nuts in large quantities; and a variety of cooked and fresh vegetables and fruits • Seeds may provide protein if the quantity consumed is large enough • Vegans do not eat any animal products; therefore, a daily supplement of 4 µg of vitamin B 12 is necessary

VEGETARIANISM • Complete protein may be obtained by eating any of the following food combinations at the same time – Legumes and whole-grain cereals – Nuts and legumes

LACTOSE INTOLERANCE • Lactose consumed by an individual with an intolerance can cause abdominal distention, discomfort, nausea, vomiting, cramps, and loose stools • Milk may be tolerated in cooked form, such as in custards or fermented dairy products • Cheese and yogurt are sometimes tolerated • Lactase, an enzyme, may be prescribed and is available as a tablet to be chewed before ingesting milk or milk products or as a liquid to add to milk • Lactase-treated milk or lactose-free products are also available commercially

PICA • Defined as eating substances that are not ordinarily considered edible or to have nutritive value • Practiced in poverty-stricken areas where diets tend to be inadequate, but pica may also be found at other socioeconomic levels • Substances most commonly ingested are dirt, clay, starch, and freezer frost • Iron deficiency anemia occurs as a result of pica

CULTURAL CONSIDERATIONS IN NUTRITION • ASIAN, CHINESE, AND JAPANESE – Important diet foods include seafood, rice, vegetables, and fresh fruits – Milk and cheese are used infrequently • JEWISH ORTHODOX – Poultry and some meat of cattle, sheep, goats, and deer are permissible; pork and pork products are not permissible – Milk and cheese may not be eaten with or within 6 hours of a meat meal

CULTURAL CONSIDERATIONS IN NUTRITION • MEXICAN – Food products include corn, chili peppers, and beans – Milk is used infrequently