NR606 Midterm Exam Questions and Answers

NR606 Midterm Exam Questions and Answers Steps for Obtaining Informed Consent -Assess pt ability to understand medical info, tx options, to make a voluntary decision. -Present relevant info with accuracy and sensitivity: • diagnosis • nature & purpose of tx options • benefits, risks, burdens of all tx options, including forgoing tx -Document informed consent conversation in the medical record, including all consent forms. Underlying assumptions for child and adolescent psychotherapy Developmental considerations Family involvement Systems involvement Resiliency Underlying assumptions for child and adolescent psychotherapy: Developmental considerations -developmental level will impact how they: • reason • approach relationships • regulate emotion and behavior • communicate -Developmental considerations • inform the diagnostic process • guide tx planning Underlying assumptions for child and adolescent psychotherapy: Family involvement -Family involvement in tx & decision-making • a norm in child and adolescent psychotherapy -invite parents to share the hx of the child or adolescent's chief complaint & prior tx, medical & developmental hx, & behavioral info privately with the therapist ahead of the session • avoid feelings of criticism or discouragement -collaborate with parent or caregiver as a tx partner Underlying assumptions for child and adolescent psychotherapy: Systems involvement -Therapists must consider the systems that surround children & adolescents & promote their development • family • school • peers • the community -Therapy can help promote the child/adolescent's socioemotional competence -help develop a community support system Underlying assumptions for child and adolescent psychotherapy: Resiliency -therapist work to promote resiliency in children & adolescents • using strength-based orientation -supports: • functioning • self-regulation • deal with challenges they faces Piaget's Stages of Cognitive Development -Sensorimotor stage: Birth-2 yrs • cognitive abilities based on reflexes • object permanence & causality -Preoperational stage: 2-7yrs • can use mental representations, symbolic thought, & language • thinking is egocentric -Concrete operational stage: 7-11yrs • logical operations when thinking/solving problems • thinking is concrete -Formal operational stage: 12yrs+ • Adolescent can use abstract reasoning in addition to logical operations • Child can understand theories, hypothesize, comprehend abstract ideas (love & justice) Screening, Brief Intervention, Referral to Treatment (SBIRT) -Screening • Quickly assesses severity of substance use & ID the appropriate level of tx -Brief intervention • Focuses on increasing insight & awareness regarding substance use & motivation toward behavioral change -Referral • Guidance to tx provides those identified as needing more extensive tx with access to specialty care Medication-Assisted Treatment (MAT) Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies. Mental health and youth -13% of children ages 8-15 experience a mental health condition -50% of children ages 8-15 experiencing a mental health condition do not receive tx -13-20% of children living in the U.S. (1 out of 5 children) experience a mental health condition in a given year -17% of high school students seriously consider suicide -1/2 of all lifetime cases of mental illness begin by age 14 Barriers to Mental Health Treatment in Children and Adolescents -lack of sufficient information or access to services -stigmas or negative perceptions towards mental health services -many drop out before receiving effective treatment, often due to: • poverty • language barriers • living in communities with scarce resources • stressors such as problems in the family violence in the community unstable housing unemployment food insecurity -Cost -scheduling conflicts -long waitlists for services -high staff turnover Prescribing Considerations for Children and Adolescents -physiologic factors impact pediatric med selection & dosing -Children, more rapid metabolism than adults, may require larger dose of med per unit of body weight -Around puberty, pharmacokinetic properties reach adult parameters • dosing after puberty may need to be decreased -Developmental considerations • attuned to signs of adverse effects, younger children may not be able to communicate complaints Kassia, a 5-year-old, is prescribed a stimulant medication for ADHD (Attention Deficit Hyperactivity Disorders) for the first time. Consider Piaget's stages, match the developmentally-appropriate education statements with the correct client: "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which ma "Do you know how it's sometimes hard for you to sit still and pay attention at school? This medicine will help you." Rationale: Kassia is in the Preoperational Stage. This stage usually lasts from ages 2-7. Children think symbolically. They learn to use words or pictures to represent objects. They are egocentric and have difficulty seeing things from others' perspectives. Preoperational thinking is very concrete. Oliver, a 10-year-old, is prescribed a stimulant medication for ADHD for the first time. Consider Piaget's stages, match the developmentally-appropriate education statements with the correct client: "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your frien "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." Rationale: Oliver is in the Concrete Operational Stage. This stage usually lasts from age 7-11. Thinking becomes more logical and organized about concrete events. Children begin to reason inductively, from specific information to general principles. The use of simile is a helpful instructional strategy for children in this stage. Tamika, a 15-year-old, is prescribed a stimulant medication for ADHD for the first time. Consider Piaget's stages, match the developmentally-appropriate education statements with the correct client: "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your frien "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your friends and parents. Do you have any concerns about taking the medication?" Rationale: Tamika is in the Formal Operational stage. This stage typically occurs at age 12 and up. Adolescents and young adults begin to reason abstractly and can consider hypothetical problems. They begin to think more about moral, philosophical, ethical, social, and political issues. Addressing Parental Concerns: Collaborative Treatment Plans -tx plans for children typically made in collaboration with parents or guardians -Collaboration between the PMHNP, clients, and families when creating the treatment plan is key to ensuring the plan meets the client's needs and is comfortable and manageable for the family Ethical Considerations in the Treatment of Children and Adolescents Privacy and HIPAA Informed Consent Mandatory Reporting Ethical Considerations in the Treatment of Children and Adolescents: Privacy and HIPAA -parents have right to req access to a minor's mental health record, including symptoms, diagnosis, tx plan • circumstances may limit that right see HIPAA fact sheet Ethical Considerations in the Treatment of Children and Adolescents: Informed Consent -Parents may decide whether to allow tx child is unable to provide true informed consent -children may not be able to give legal consent, should be included in discussions about med & tx whenever possible • encourage tx adherence Ethical Considerations in the Treatment of Children and Adolescents: Mandatory Reporting -PMHNPs mandated reporters in most states • required to report suspicions about abuse or neglect to the appropriate authorities -federal & state statutes include stipulations related to mandatory reporting -PMHNPs responsible for following all relevant statutes in their state of practice most common complication during the perinatal period? Mental health problems maternal mental health -Up to 1 in 5 women will suffer from a maternal mental health disorder like postpartum depression -15% of women receive tx -1 in 7 will experience depression during pregnancy -Up to 50% of women living in poverty will suffer from a maternal mental health disorder -Maternal mental health disorders impact the whole family, not just moms -More than 600,000 women will suffer from a maternal mental health disorder in the U.S. ever year -Anxiety & depression have risen 37% in teen girls. This will increase the number of women suffering postpartum depression in the future -Rates of depression are more than doubled in Black moms due to cumulative effects of stress called weathering Ethical Considerations in Maternal Mental Health Tx -PMHNP must carefully weigh the risks & benefits r/t starting, continuing, switching, or discontinuing med therapy during the perinatal period -work to create tx plans that respect clients' goals & perspectives Prescribing Considerations in Maternal Mental Health Tx -Pharmacologic therapy during pregnancy may be necessary to prevent maternal and fetal harm • health of the embryo or fetus depends on health of the mother -risks and benefits of all psychoactive medications to both the pregnant client and fetus must be considered -risks and benefits of prescribing medications for breastfeeding clients must also be considered • many drugs cross from the maternal circulation into breast milk and may pose harm to the nursing baby Prescribing Considerations in Maternal Mental Health Tx: Pregnancy -Nearly 50% of pregnancies are unplanned -when prescribing for pts of reproductive age take into consideration that pregnancy may occur • initiate discussions about medication safety -may work with the pt 6-12 months before a planned pregnancy to adjust meds as needed -be prepared to provide guidance to pts who have already conceived -Most meds can be continued during pregnancy -if tx plan includes med contraindicated during pregnancy: • discuss pts intended method of birth control • contingency plan for unplanned pregnancy -decision made to D/C medication, drugs should be tapered whenever possible -Communication throughout the pregnancy is crucial to ensure client safety if symptoms worsen -physiologic changes during pregnancy impact pharmacokinetics of many meds • increase blood plasma level may increase the distribution volume of certain meds • Hormonal changes in CYP450 may increase or decrease drug metabolism • Increased renal blood flow & GFR may speed the excretion Prescribing Considerations in Maternal Mental Health Tx: Lack of Evidence -psychoactive medications in the perinatal period • paucity of evidence regarding the true risks for the pregnant client and developing fetus limited as pregnant women and newborns are frequently excluded from medication research Prescribing Considerations in Maternal Mental Health Tx: Switching Medications During Pregnancy -switching meds during pregnancy can create a high risk for destabilization of mental illness • puts both the client and fetus at risk for stress & trauma • increases the absolute # of substances to which the fetus is exposed may increase risk for adverse outcomes -If stable on current med regimen, typically better to continue current regimen Allie is a 26-year-old who has been receiving treatment for bipolar I disorder for 3 years. Her symptoms have been in remission with lithium 500 mg twice daily. She also completed 12 weeks of interpersonal and social rhythm therapy (IPSRT) upon diagnosis and used the life charting methodology to track her symptoms. She calls her PMHNP and states "I just found out I'm pregnant. My partner and I were not expecting this, but we are excited! I am worried about what lithium will do to my baby. Sh schedule an appointment for Allie and her husband to discuss a treatment plan as soon as possible ask Allie to continue taking lithium at the current dose for now recommend that Allie begin tracking her mood, sleep schedule, and other symptoms Rationale: Rationale: The PMHNP should schedule an appointment as soon as possible to discuss Allie's treatment plan during her pregnancy. Discontinuation of medications for pregnancy is associated with a relapse rate of 80-100% for clients who take mood stabilizers; therefore, the client should not abruptly cease taking lithium (Ortega et al., 2023). Clients with a diagnosis of bipolar disorder may benefit from tracking the symptoms of their illness, especially during stressful times. Although reassurance is appropriate, the PMHNP should not minimize the potential risks of continuing medication by telling the client that no harm will come to the baby. Discontinuation of medications for pregnancy is associated with a relapse rate of ___________% for clients who take mood stabilizers 80-100% Informed consent: pregnancy -must initiate discussion with pt regarding informed consent for tx • whether new symptoms during pregnancy or already established with care • risks of continuing current meds and the risks of stopping them -help pt process their risk factors & tx hx to make an informed decision -if must remain on high-risk medications such as valproic acid should be thoroughly evaluated by the multidisciplinary team including a perinatal psychiatrist -Documentation should note whether the woman plans to continue with treatment or discontinue the medication Kenya is a 36-year-old who has been taking fluoxetine for three years for major depressive disorder. Her symptoms are currently in remission, and she just found out that she is 7 weeks pregnant. She calls the PMHNP to discuss whether she should continue her medication during pregnancy. After the discussion, Kenya indicates that she will remain on her medication. Which of the following should be included in the discussion and documentation of the call with Kenya? Select all that apply. rare adve rare adverse effect of persistent pulmonary hypertension in the neonate common adverse effect of postnatal abstinence syndrome potential risks of discontinuing treatment to both mother and baby decision to continue treatment Rationale: The PMHNP should disclose all common adverse effects and discuss serious adverse effects associated with the medication, regardless of incidence. The discussion should include the potential risks to both mother and baby if the medication is discontinued. Documentation should include the client's decision whether to continue or discontinue treatment. Since fluoxetine is not a high-risk medication for pregnancy, the PMHNP need not refer the client to a perinatal psychiatrist for medication management. Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Depression & Anxiety -SSRIs are first-line treatments for depression and anxiety during pregnancy -SNRIs, tricyclic's, & bupropion are also considered safe tx options -most common adverse effect with SSRIs & SNRIs is neonatal withdrawal syndrome • Symptoms: tremors, high-pitched crying, disturbed sleep (peaks 2-4 days after birth) • impacts up to 30% of babies born to mothers who take antidepressant medication • no evidence D/Cing or tapering dosages in last trimester reduces risk to infant -Paroxetine may increase risk of atrial septal defects -Benzodiazepines taken with caution for anxiety • risk of newborn toxicity must be considered and monitored if used • Symptoms: sedation, floppy muscle tone, potential breathing issues at birth Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Bipolar Disorder -Lamotrigine considered safe during pregnancy • may not be effective for manic episodes -Lithium exposure during first trimester has small but significant risk of cardiac malformations • increases with higher doses • risks and benefits carefully considered, Consider the gestational age of the embryo and fetus -AVOID DURING PREGNANCY • valproic acid and carbamazepine are considered teratogenic Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Psychosis -atypical antipsychotic medications, particularly olanzapine and quetiapine • increased risk of gestational diabetes D/Cing may not decrease the risk • increased risk of large for gestational age infants -Olanzapine increase the risk of musculoskeletal malformations in infants -Risperidone & quetiapine are the most used antipsychotics during pregnancy • Neither cause malformations -Antipsychotic meds may cause neonatal withdrawal symptoms • close monitoring of newborn several days after delivery Johnita has been taking sertraline 100 mg daily for 4 years for major depressive disorder. Her symptoms have fluctuated over the past year. She is 10 weeks pregnant. Which of the following is the most appropriate recommendation for Johnita? continue sertraline 100 mg daily decrease sertraline to 50 mg daily increase sertraline to 150 mg daily discontinue sertraline continue sertraline 100 mg daily Rationale: Sertraline is considered a safe medication during pregnancy. The client's symptoms have fluctuated on her current medication dose; therefore, decreasing the dose may cause a relapse of symptoms. Alexandra has been taking lithium 1200 mg orally in two divided doses of 600 mg each for bipolar I disorder. She has been in remission of symptoms for 14 months. She is 7 weeks pregnant. Which of the following is the most appropriate recommendation for Alexandra? obtain serum lithium levels before tapering the lithium dose decrease dose to 600 mg daily decrease dose to 900 mg daily discontinue lithium and switch to lamotrigine obtain serum lithium levels before tapering the lithium dose Rationale: Lithium exposure during the first trimester has a small but statistically significant risk of cardiac malformations; the risk increases with higher dosages of the medication. Obtaining serum lithium levels before tapering the dose is indicated since Alexandra has bipolar I disorder and is stable. The development of the heart begins as early as the third week of gestation with the 4-chamber fetal heart formed by gestational week 7. By the time Alexandra is weaned the risk has passed as the heart is already formed. Although lamotrigine is considered safe during pregnancy, it may not be appropriate for clients who have experienced mania in the past. Saoirse takes aripiprazole 30 mg daily for a diagnosis of schizophrenia. She has taken the medication throughout her pregnancy and is now 34 weeks pregnant. She is concerned about the risks of neonatal withdrawal syndrome once her child is delivered. Which of the following is the most appropriate recommendation for Saoirse? continue taking aripiprazole 30 mg daily taper aripiprazole dose over 2 weeks to 15 mg daily and then increase to 30 mg after delivery discontinue aripiprazole at 38 weeks continue taking aripiprazole 30 mg daily Rationale: Although neonatal withdrawal syndrome can occur in newborns who are exposed to second-generation antipsychotics, reducing or discontinuing aripiprazole or switching to another antipsychotic medication may cause destabilization in the client. The infant may need a few days of additional monitoring after delivery, but the client should remain on her optimized dose. Breastfeeding -American Academy of Pediatrics advocates breastfeeding through the first 6 months of life -most psychotropic medications pass into breast milk • If infant exposed to med in utero, may discuss continuing med during breastfeeding, unless has severe side effects for infant -req new or additional prescriptions while breastfeeding • discuss whether benefits of breastfeeding outweigh the risks of exposure to the infant • bottle feeding may be the best option -Pts must be educated to support informed choice & their preferences must be supported Safe for Breastfeeding -SSRIs -Benzodiazepines -Valproic acid -Quetiapine Safe for Bottle Feeding -Lithium -Lamotrigine -Clozapine Substance Use Disorders During the Perinatal Period -Perinatal SUDs are an urgent public health crisis • increasing across all groups of childbearing people rates rising rural or low-income communities & those with Medicaid coverage for maternity care -greatest risk for life-threatening outcomes of SUDs is among people of color. -hallmark symptoms of SUDs: behavioral, physical, and psychological dependence -most used substance in the perinatal period is tobacco, followed by alcohol, cannabis, and other illicit drugs • use of prescription & illicit opioids also increasing -In US: 70, 000 maternal overdose deaths in 2018, 69% were related to opioid use Health Risks Associated with SUDs: Tobacco No tobacco product is considered safe for use during the perinatal period -Smoking-related pregnancy complications: • ectopic pregnancy • placental abruption • placenta previa • fetal mortality • stillbirth • preterm birth • low birth weight infants -Smoking-related effects on neonates: • sudden infant death syndrome • birth malformations oral clefts neural tube defects -Smoking-related effects on infants, children, and adolescents: • asthma • cognitive impairment • lower respiratory illness • ADHD • central nervous system tumors Health Risks Associated with SUDs: Alcohol -Drinking while pregnant costs the US $5.5 billion -CDC: no safe time to drink during pregnancy, no safe quantity of alcohol to consume while pregnant or trying to get pregnant -1st trimester exposure correlates with the most significant alcohol-related birth outcomes -increased risk for miscarriage, stillbirth, congenital anomalies, low birth weight, small for gestational age, and preterm delivery -Lifelong effects of AUD on children: • fetal alcohol spectrum disorders (FASDs) • neurodevelopmental & CNS deficits • speech & language challenges • cognitive & behavioral deficits • impaired executive functioning • psychosocial difficulties in adulthood fetal alcohol spectrum disorders (FASDs) Up to 1 in 20 US school children may have FASDs -Physical Issues: • low birth weight and growth. • problems with heart, kidneys, and other organs. • damage to parts of the brain. Leads to... -Behavioral and intellectual disabilities: • learning disabilities and low IQ • hyperactivity • difficulty with attention • poor ability to communicate in social situations • poor reasoning and judgment skills Can lead to... -Lifelong issues with: • school and social skills • living independently • mental health • substance use • keeping a job • trouble with the law Health Risks Associated with SUDs: Cannabis -often combined with other substances -associated with: • preterm labor • low birth weight • small for gestational age deliveries • adverse effects on fetal and adolescent brain growth • adverse effects on executive functioning skills • behavioral problems • adverse effects on academic achievement -All forms of cannabis have adverse effects, even medical marijuana Marijuana Possible Effects on Your Fetus -Disruption of brain development before birth -Smaller size at birth; higher risk of still birth -Higher chance of being born too early, especially when a woman uses both marijuana and cigarettes during pregnancy -Harm from second-hand marijuana smoke: Behavioral problems in childhood and trouble paying attention in school Marijuana Possible Effects on You -Permanent lung injury from smoking marijuana -Dizziness, putting you at risk for falls -Impaired judgment, putting you at risk of injury -Lower levels of oxygen in the body, which can lead to breathing problems Health Risks Associated with SUDs: Cocaine -majority of women addicted to cocaine are of childbearing age -linked with poor pregnancy-related outcomes: • premature rupture of membranes • placental abruption • preterm birth • low birth weight • small for gestational age deliveries, as well -long-term effects in children and adolescents: • lower short-term memory • child and adolescent delinquent behavior • earlier age of sexual activity • substance use Health Risks Associated with SUDs: Opioids -epidemic in the U. S. -Opioid use disorder (OUD) during pregnancy, including heroin & prescription opioids, increases risk of maternal life-threatening health problems & death by 50% -greater risk of eclampsia, heart attack or heart failure, & sepsis -Infants experience significant adverse effects: • neonatal abstinence syndrome (NAS) • increased risk of toxemia • low birth weight • respiratory complications • third trimester bleeding and mortality • postnatal growth deficiency • microcephaly • neurobehavioral problems • sudden infant death syndrome (SIDS) -4x as many infants were born with neonatal abstinence syndrome (NAS) in 2014 than in 1999 neonatal abstinence syndrome (NAS) -caused by maternal opioid use -affects between 45% to 94% of infants exposed to opioids in utero -accounted for $3 billion in hospital costs over the last decade SUDs in childbearing people: Ethical and Legal Considerations -beneficence • treat these clients with dignity and respect -nonmaleficence • prevent or avoid harm, including harms of omission -justice • have right to equitable access to care, resources, & nondiscriminatory healthcare -autonomy • have right to comprehensive info about their health & healthcare • power to make decisions about their healthcare *stigma to perinatal substance use endangers fundamental rights Stigma According to the National Center on Substance Abuse and Child Welfare SUD-related stigma occurs on three levels: structural, public, and self -Structured Stigma (institutional stigma): policies, regulations, or laws that intentionally or unintentionally lead to discrimination • can limit access to resources and other opportunities -Public Stigma: attitudes, beliefs, & behaviors of groups or ind's which form a stereotype • creates an emotional reaction or prejudice and results in discrimination -Self-Stigma: the shame individuals internalize about negative stereotypes • may lead to feelings of being flawed or unworthy of love or connection • may prevent them from seeking help A program policy that prohibits individuals from using specific forms of prescribed medication for addiction (MAT) treatment is an example of __________ stigma structural A stereotypic belief that individuals choose to use alcohol or other drugs and blame them for their substance use disorder is an example of _________ stigma public Madden (2019) has proposed a new category of stigma: intervention stigma -"Individuals working in [medication-assisted treatment] MAT experience discrimination and prejudice from other healthcare professionals -discrimination & prejudice stem at times from stigma toward addiction diagnoses Structural Stigma in U.S. Drug Policies -nation's drug policies tend to follow 1 of 2 diff. aims: • offering medical care such as MAT • criminalizing behaviors associated with substance use -Fear of legal repercussions and the involvement of children's services may lead women to avoid reporting substance use • # of states with punitive policies/requirements for providers to report suspected prenatal drug use has more than doubled in the last decade, resulting in poor health outcomes State Policy on Substance Use During Pregnancy -authorizing civil commitment -criminalizing the behavior as child abuse or neglect -requiring providers to notify child protective services when an infant is affected by illegal substance abuse -requiring providers to report or test for prenatal drug exposure, which is permissible evidence in child-welfare proceedings In 2023, the Guttmacher Institute reported: -24 states and the District of Columbia consider prenatal substance use to be child abuse -3 states and the District of Columbia consider it grounds for civil commitment -25 states and the District of Columbia mandate provider reporting of suspected prenatal drug use -8 states require providers to test for prenatal drug exposure if drug use is suspected -19 states have created or funded drug treatment programs specifically for pregnant people -10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people Of pregnant women who were anonymously tested for drug use, the prevalence of use was found to be similar between Black and White women, but Black women were _____ times more likely to be reported to law enforcement. 10x _______________ women suffer from higher SUD rates compared to other racial and ethnic groups and are disproportionately affected by criminalization laws at the federal, state, and tribal levels. Indigenous Consistent use of medication for OUD treatment during pregnancy is significantly lower for ________________________. women of color substance use during pregnancy Assessment and Screening -The U.S. Preventative Services Task Force (USPSTF) and ACOG have recommended the Brief Intervention and Referral to Treatment (SBIRT) approach • screen for substance use during the perinatal period -Validated screening tools for substance use during pregnancy • Substance Use Risk Profile-Pregnancy scale (SURP-P) • 4P's Plus can also include validated screening questions for depression & domestic violence SUD Treatment in the Perinatal Period -not contraindicated -associated with better outcomes for both the pregnant person & the fetus -pharmacological & nonpharmacological approaches -Goals of tx: • abstinence or reduction of substance use • prevention of adverse effects due to substance use or withdrawal on the pregnant person & fetus • reduction of high-risk behaviors associated with substance use • improved quality of life & social conditions Perinatal Period: Alcohol Use Disorder Tx -advise pregnant clients who use alcohol to abstain or minimize use during pregnancy and breastfeeding -Behavioral therapy and harm reduction counseling -little info is available of acamprosate and naltrexone safe use during pregnancy -Inpatient tx recommended for pts at risk for moderate, severe, or complicated alcohol withdrawal • indicated by a score of 10 on the CIWA-Ar Perinatal Period: Tobacco Use Disorder Tx -advise clients to discontinue tobacco use during pregnancy -perform or refer clients for psychotherapy & support -review risk & benefits with pt, nicotine replacement therapy (NRT), bupropion, or a combination of these interventions may be initiated • Higher doses of NRT may be req in pregnant pt due to metabolic changes of pregnancy -immediate-release preparations, gum or inhaler, can help minimize infant exposure during pregnancy & breastfeeding -Insufficient evidence for the use of varenicline bupropion exposure in the fetal period is associated with: -slightly elevated rates of congenital heart defects • overall number remains low