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Antimicrobial agents given during the catarrhal stage may lessen the severity of the disease buy gyne-lotrimin 100 mg. Tuberculosis Tuberculosis is caused by infection with organisms of the Mycobacterium tuberculosis complex gyne-lotrimin 100 mg line, which primarily affects the lungs gyne-lotrimin 100mg without prescription. Clinical manifestations include feelings of sickness or weakness buy discount gyne-lotrimin 100mg on line, weight loss, fever, and night sweats. Isolation of M tuberculosis by culture from early morning gastric aspirate, sputum, pleural fluid, or other body fluids establishes the diagnosis of active dis ease. Smears to demonstrate acid-fast bacilli should be performed on sputum and body fluids. The purpose of treating latent tuberculosis infection is to prevent progression to disease. When the result of a tuberculin skin test or interferon-gamma release assay is positive, the time of conversion usually is not known. If a chest X-ray is normal, some experts prefer to delay treatment of latent tuberculosis infection until after delivery because preg nancy itself does not increase the risk of progression to disease and because of an increased risk of drug-induced hepatotoxicity during pregnancy and immediately postpartum. For this reason, the recommended medication in women known to have converted within the previous 2 years (such as known contacts of other tuberculosis cases) but with no evidence of disease is isoniazid (300 mg per day) starting after the first trimester and continuing for 9 months. Isoniazid and rifampin, supplemented initially by ethambutol are recommended drugs. On the rare occasions in which congenital tuberculosis is suspected, diagnostic evaluations and treat ment of the infant and the mother should be initiated promptly. Management of a newborn whose mother (or other household contact) is suspected of having tuberculosis is based on individual considerations. Differ ing circumstances and resulting recommendations are listed as follows: • the mother has a positive tuberculin skin test or interferon-gamma release assay result but a negative X-ray result. If the mother is asymptomatic, the infant needs no special evaluation or therapy and no separation of the mother and the infant is required. Because the tuberculin skin test or interferon-gamma release assay result could be a marker of an unrecog nized case of contagious tuberculosis within the household, other house hold members should be tested and have further evaluation, as needed. In the latter case, the mother may develop contagious, pulmonary tuberculosis, if untreated, and should receive appropriate therapy if not treated previously. The mother should be reported immediately to the public health department so that investigation of all household members can be per formed within several days. All contacts should have a tuberculin skin test or interferon-gamma release assay, chest X-ray, and physical exami nation. Because the response to the vaccine in infants may be delayed, the infant should be separated from the ill family member for at least several weeks after vaccination. In general, in the United States directly observed therapy of the infant is preferred. An expert in childhood tuberculosis should be consulted when this is a consideration. Acquired 428 Guidelines for Perinatal Care syphilis almost always is contracted through direct sexual contact with ulcer ative lesions of the skin or mucous membranes of infected people. Congenital syphilis most often is acquired through hematogenous transplacental infection of the fetus, although direct contact of the infant with infectious lesions during or after delivery also can result in infection. Transplacental infection can occur throughout pregnancy and at any stage of maternal infection. Antepartum Management All pregnant women should be serologically screened for syphilis as early as possible in pregnancy. False-negative serologic test results may occur in early primary infection, and infection after the first prenatal visit is possible. For communities and populations with a high prevalence, serologic testing also is recommended at 28–32 weeks of gestation and at delivery (as well as after exposure to an infected partner). Pregnant women with syphilis should be treated with a penicillin regimen appropriate to the stage of infection. Women who are allergic to penicillin should be desensitized and then treated with the drug. Erythromycin and azithromycin are suboptimal treatment options because neither reliably cures maternal infection nor treats an infected fetus. Women should be observed for signs of a Jarisch– Herxheimer reaction (an immune response to toxins released when spirochetes die), which may cause fever, nonreassuring fetal status, and preterm labor. Algorithm for evaluation and treatment of infants born to mothers with reactive serologic test results for syphilis. If any part of the infant’s evaluation is abnormal or not performed, or if the cerebrospinal fluid analysis is rendered uninterpretable, then a 10-day course of penicillin is required. Use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer either the same as or less than fourfold (eg, 1:4 is fourfold lower than 1:16) the maternal titer are at minimal risk of syphilis if they are born to mothers who completed appropriate penicillin treatment for syphilis during pregnancy and more than 4 weeks before delivery, and if the mother had no evidence of reinfection or relapse. Although a full evaluation may be unnecessary, these infants should be treated with a single intramuscular injection of penicillin G benzathine because fetal treatment failure can occur despite adequate maternal treatment during pregnancy. Alternatively, these infants may be examined carefully, preferably monthly, until their nontrepone mal serologic test results are negative. Some experts, however, would treat with penicillin G benzathine as a single intramuscular injection if follow-up is uncertain. The early localized stage of the disease is characterized by a distinctive “bull’s-eye” skin lesion (erythema migrans) that occurs in 60–80% of patients and nonspecific, flu-like symptoms. A late manifestation of Lyme disease is relapsing arthritis, usually pauciarticular and affecting large joints. Patients in the later stages of Lyme disease usually will be seropositive, but false-positive and false negative test results are common.
Indeed buy generic gyne-lotrimin 100mg line, it might be more costly to order gyne-lotrimin 100mg with visa try to discount gyne-lotrimin 100mg without a prescription select out parts of the genome for sequencing than to buy discount gyne-lotrimin 100mg online sequence all of it. One could imagine, however,thatcoveragedecisionsmightdiferentiatebetweenwhatkindofgenomicinformationwasanalysed and disclosed given that the interpretation of the sequence is the more costly part of genome sequencing. Parentsmightidentifythediseaseand/ornon disease traits they wanted to select against or for and the relative weights they would assign these categories, or they could just rank features most important to them and let the algorithm assign relative weights. Some might fnd it too difcult or abstract to assign rankings or relative weights to diferent kinds of genomic informa tion. For example, they could create algorithms that award points for genotypes associated with diseases based on various categories: the potential severity, age of onset, degree of impairment or physical sufering, etc. Diferent weights would be assigned to diferent categories and the scores would be discounted by the probabilistic association between the vari ants and phenotype (penetrance). The resulting scores, based on the genomic profle of each embryo, would be used to se lect embryos for implantation. The outcome of these algorithms would depend as much on the weights assigned to the categories as to the determination of which categories to use. Two algorithms that used the same categories could lead to very diferent out comes if diferent weights were assigned to each category. In other words, the formulas could have signifcant impact on the selection of embryos. Individualized features could be used to modify generic algorithms based on key parental dislikes or predilections regarding medical and non-medical traits. Parents might indicate that a specifc category of disease risk, such as a propensity for conditions that require specialized diets, like Celiac disease, would be a deal breaker. All embryos 121 As noted above, cost may infuence whether clinics are able to ofer more than one algorithm package. To the extent that individuals have the wherewithal to choose among diferent clinics, the type of algorithm the clinic ofered might infuence their choice of clinics. Algorithms might also factor in whether the variant is associated with great variability in expressivity. The former are normally measured on a scale in which 1 represents full health and 0 represents death, therefore higher values correspond to more desirable statesandstatesdeemedworsethandeathcantakenegativevalues. Telateraremeasuredonascaleinwhich 0 represents no disability, therefore lower scores correspond to more desirable states. Conversely, only embryos with a signifcantly increased propensity for a particular trait, such as vari ants associated with intelligence (assuming a meaningful correlation between variant and trait)126 would be selected for ranking according to the generic algorithm. Individualized algorithms could ofer parents the opportunity to decide what kinds of non-medical traits they wanted to include and the weight they would assign those traits. Alternatively, clinics might ofer generic algo rithms that include certain non-medical traits, perhaps relying on surveys of commu nity preferences or based on the degree to which they were associated with ‘success’ or other measures of well-being, however defned or understood. As with variants associ ated with disease, values assigned to traits would have to be discounted based on the probabilities of expression. For example, it is unlikely that providers would let future parents decide whether or not to select embryos based on lethal or debilitating childhood illnesses like Tay Sachs or Lesch Nyhan. Most clinics would likely use algorithms with a baseline selection against such devastating conditions. A more complicated issue is whether providers would be willing to honor other kinds of requests, particularly those that involve the selection for less serious disabilities. Some clinics, however, will implant such embryos,129 125 Of course, one would have to decide what constituted a signifcantly increased propensity. The mosthighlyrankedembryoswouldthenbefurthernarroweddownbasedonparentalinputaboutafewtraits that they particularly valued or considered deal breakers. Even with respect to a particular trait, like height, diferent genetic variants can have signifcantly difer ent impacts. As she points out, ‘providers are not obligated to meet every patient demand for treatment. It found that ‘valid and reasoned arguments exist to support provider decisions to assist in transfer ring genetically anomalous embryos, and in declining to assist such transfers’. In cases ‘in which a child is highly likely to be born with a life-threatening condition that causes severe and early debility with no possibility of reasonable function’,133 however, the Commitee found that ‘[p]hysician assistance in the transfer of [such] embryos is ethi cally problematic and highly discouraged. Some might ofer highly individualized algorithms for those who wanted full choice; others might ofer more limited individualized algo rithms. Still others might ofer some kind of generic algorithm for those who wanted more assistance: generic algorithms that focus on health features, such as a reduced risk of serious childhood illnesses; generic algorithms that include non-medical traits, such as a propensity for athleticism or ‘success’; etc. Niche segments of the fertility market might emerge to cater to diferent kinds of decision-making preferences much as dating sites135 and sperm banks have done to help individuals fnd the ‘ideal’ match or donor, respectively, from a potentially vast pool of candidates. Some dating services, for example, allow members to browse the profles of all members with ‘optional tests, quizzes, or guides’ to help members fnd their love interests. Although ‘the key value’ driving these decisions ofen tends to be ‘ensuring a prospective child’s safety and welfare and not risking the welfare of the prospective mother’—for example, when pregnancy would endan ger the woman or there is a history of the man abusing existing children—clinics are just as likely to ofer fertility treatment to couples who receive welfare, gay couples, or single men as they are to deny such treat ment. She notes that discussions of physician autonomy tend to address conscien tious objection to decisions such as abortion and/or refusal to ofer futile care. Fairfax Cryobank, for example, ofers an advanced search that allows for greater specifcity than its basic search with respect to ethnicity (fned tuned by country of origin), shades of skin tone (medium light, medium dark, light, dark, or medium), hair type (straight, curly, wavy), etc. It also ofers a lifestyle search that selects donors based on astrology sign, favorite subject, religion, favorite pet, personal goals, and talents. Flex Matches don’t meet the match selection criteria the member indi cates is most important, and occur when ‘eHarmony is unable to fnd matches that meet your exact Match Selection criteria, but can sometimes uncover matches that are unexpectedly compatible.
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If osteochondritis dissecans is sus of the proximal tibia forms the pes anserine pected generic 100 mg gyne-lotrimin with visa, recommended radiographs include bursa buy gyne-lotrimin 100 mg low cost. Tightness of the iliotibial band discount gyne-lotrimin 100mg visa, excessive foot pronation purchase gyne-lotrimin 100mg without a prescription, Pain symptoms are usually most prominent genu varum, and tibial torsion are predisposing factors for with the knee at 30 degrees of flexion. Injury to monly, osteoarthritis of the medial compart the anterior cruciate ligament usually occurs ment of the knee. Resultant val may be worsened by repetitive flexion and gus stress on the knee leads to anterior dis extension. On physical examination, tender placement of the tibia and sprain or rupture of ness is present at the medial aspect of the knee, the ligament. Valgus stress testing in the hours after the injury indicates rupture of the supine position or resisted knee flexion in the ligament and consequent hemarthrosis. Radio On physical examination, the patient has a graphs are usually not indicated. The anterior drawer test tween the iliotibial band and the lateral may be positive, but can be negative because femoral condyle can lead to iliotibial band ten of hemarthrosis and guarding by the ham donitis. The Lachman test should be occurs in runners and cyclists, although it may positive and is more reliable than the anterior develop in any person subsequent to activity drawer test (see text and Figure 3 in part I of involving repetitive knee flexion. Injury to reports pain at the lateral aspect of the knee the medial collateral ligament is fairly com joint. The pain is aggravated by activity, par mon and is usually the result of acute trauma. On physical examination, tenderness is places valgus stress on the knee, followed by present at the lateral epicondyle of the femur, immediate onset of pain and swelling at the approximately 3 cm proximal to the joint line. Valgus Noble’s test is used to reproduce the pain in stress testing of the knee flexed to 30 degrees iliotibial band tendonitis. With the patient in a reproduces the pain (see text and Figure 4 in supine position, the physician places a thumb part I of this article1). Injury of swelling of the knee with no antecedent the lateral collateral ligament is much less trauma. Even slight usually results from varus stress to the knee, as motion of the knee joint causes intense pain. Instability or protein content (greater than 3 g per dL [30 g pain occurs with varus stress testing of the per L]), and a low glucose concentration knee flexed to 30 degrees (see text and Figure 4 (more than 50 percent lower than the serum in part I of this article1). The meniscus can be torn Common pathogens include Staphylococcus acutely with a sudden twisting injury of the aureus,Streptococcus species, Haemophilus knee, such as may occur when a runner sud influenzae, and Neisseria gonorrhoeae. Atrophy of the vas sents with knee pain that is aggravated by tus medialis obliquus portion of the quadri weight-bearing activities and relieved by rest. The the patient has no systemic symptoms but McMurray test may be positive (see Figure 5 in usually awakens with morning stiffness that part I of this article1), but a negative test does dissipates somewhat with activity. Evaluation of patients Acute inflammation, pain, and swelling in presenting with knee pain: part I. Hip and pelvic injuries in the Even minimal range of motion is exquisitely young athlete. Pediatric and adolescent sports Arthrocentesis reveals clear or slightly medicine. Anterior knee pain: mm (2 to 75 10 per L), a high protein con the challenge of patellofemoral syndrome. Orthopaedic mately 75 percent of the serum glucose con sports medicine: principles and practice. Philadel the synovial fluid displays negatively birefrin phia: Saunders, 1994:1249-60. Popliteus tendinitis: tips gent rods in the patient with gout and posi for diagnosis and management. Definitive diagnosis of a popliteal cyst with deposition of calcium pyrophosphate or hy droxyapatite. Using the term patella alta, we performed found it was increased (>52 mm to >56 mm). Only 2 review or measurement of human patellar height on plain studies suggested an ideal patellar height after surgery. All Different procedures were used to treat patella alta: evidence levels were included. The 92 medialization, and distal advancement of the patellar original study articles defned patella alta mostly with tendon. On the other hand, patella alta may also be a normal variant of a person’s knee anatomy and Modified Insall-Salvati index (20°)27 1 >1. Radiograph Ratios Measured on Magnetic Resonance Methods Imaging In February 2017, using the term patella alta, Index/Ratio N = 23 Cutoff for Patella Alta we performed a systematic literature search on PubMed. Excluded were abstracts and articles in languages other than Blackburne-Peel index (20°) 1 >1. Of the 92 original study articles, 17 We assessed measurement methods, report (18. Patella alta was described as a patella that techniques, and postoperative target values. Four different patella itary or congenital disease, 1 for extensor appa alta measurement methods were used: lateral ratus rupture, 3 for editorial letter, and 6 for other radiographs with corresponding ratios (68 studies, reasons.
She has had two previous admissions to 100 mg gyne-lotrimin fast delivery hospital within the last 6 months purchase gyne-lotrimin 100mg without a prescription, once for an overdose of heroin and once for an infection in the left arm buy cheap gyne-lotrimin 100mg on line. The heart sounds are normal and there are no abnormal findings on examination of the respiratory system discount gyne-lotrimin 100mg fast delivery. The respiratory rate is18/min, jugular venous pressure is not raised, there are no new heart murmurs and oxygen saturation is 97 per cent on room air. This complication is not unusual in intravenous drug users and can be associated with sepsis although there was no sign of this on the initial investigations. She has been treated for the thrombosis and for alcohol withdrawal and her opiate use. The deep vein thrombosis would have predisposed her to a pulmonary embolus, but the normal respiratory rate, lack of elevation of jugular venous pressure and normal oxygen saturation make this unlikely. As an intravenous drug user she might have taken more drugs even under supervision in hospital. The tachycardia and lowered blood pressure raise the possibility of haemorrhage which might be precipitated by the anticoagulants. In an intravenous drug user one would think of infective endocarditis which may occur on the valves of the right side of the heart and be more difficult to diagnose. Lung abscesses from septic emboli are another possibility in an intravenous drug user with a deep vein thrombosis, and a chest X-ray should be taken although the lack of respiratory symptoms makes this less likely. In this case the intravenous line has been left in place longer than usual because of the difficulties of intravenous access and it has become infected. Lines should be inspected every day, changed regularly and removed as soon as possible. On recovery and discharge there were problems with the question of anticoagulation. Warfarin treatment raised difficulties because of the unreliability of dosing, attendance at anticoagulant clinics and blood sampling. It was decided to continue treatment as an out patient with subcutaneous heparin for 6 weeks. Harvey Introduction Diagnostic Approach More than half of all occupational disorders can be at As with the evaluation of any musculoskeletal disorder, tributed to chronic tendinous pathologies . In greater than in patients who perform jobs that are low in acute pathology, patients can frequently localize the area repetitiveness and force . A number of terms have of most signicant pain with one nger and this can be been used to categorize wrist and hand tendon disorders the most important diagnostic clue (Table 15-1). These terms reect a common presumed etiology provocative testing and selective anesthetic injections. Chronic tendon disorders are also sound is still controversial, although, in selected cases, frequently seen in various sporting activities, both at pro both of these imaging techniques can be important for fessional and amateur levels. Other sports commonly associated Nonoperative Management with wrist tendinopathies include golf, weightlifting, gymnastics, and bicycling [3,4,5]. As with chronic tendon disorders in other parts of the Because of the complex organization of tendons about body, nonoperative therapy is almost always the initial the wrist and hand, reaching an exact diagnosis can be management of choice in hand and wrist tendon disor difcult. This may include rest, with limitation of the incit site in order to contrast diagnoses. Common differential ing activity, part-time immobilization using removable diagnoses for each region are presented in tabular form splints, complete immobilization using casts or, more (Table 15-1). Regardless of the etiology, chronic tendon commonly in the hand and wrist, nonremovable orthoses. The initial course of non inciting event is not discontinued (in a professional operative treatment is generally the same regardless of athlete or laborer), as their analgesic effect may allow in anatomical site. Surgical intervention in tendon pathol creased mechanical loading, leading to rupture. The therapy offers both acute anti-inammatory management authors’ preferred surgical approach will be discussed in (ice, ultrasound, and electrical modalities) and long-term detail within each anatomical subsection. They travel through a bro-osseous tunnel (rst dorsal extensor com Dorsoradial 1. De Quervain’s tenosynovitis (1st extensor compartment) partment) and form the radial border of the anatomical 2. Further divi compartment) sion within the bro-osseous tunnel by a septum has been 3. Scaphoid cysts/fracture More specically, the patient usually presents with a com 5. Linburg’s syndrome present for many months prior to seeking medical atten Volar-ulnar 1. Steroid injections of tendon demonstrated by a palpable and sometimes audible sheaths remain an effective form of treatment, although “click” with active extension of the thumb, is an uncom controversy continues to exist regarding their safety and mon (prevalence of 1. The test is performed passively by deviat Once the patient is asymptomatic (whether by opera ing the wrist ulnarly with the thumb lying along the tive or nonoperative means), a period of rehabilitation palmar aspect of the index lightly clenched within the emphasizing proprioception and controlled activity ngers. Clenching the thumb too tightly causes pain even simulation prior to returning to full activity is essential. Finkelstein’s test reproduces the Recurrence of the tendinopathy can be common if this patient’s symptoms, with pain along the rst extensor part of the treatment protocol is ignored. Resisted thumb extension can also work hardening program involving occupational therapy provoke the symptoms but is a less reliable test. The differential diagnosis includes intersection Dorsal-Radial Wrist Pain syndrome, which usually presents with pain more proxi mally (see Intersection Syndrome).
Perinatal Medical Care Providers Perinatal medical care providers include obstetricians purchase 100mg gyne-lotrimin mastercard, pediatricians order gyne-lotrimin 100mg free shipping, laborists gyne-lotrimin 100 mg without prescription, obstetric–gynecologic and pediatric hospitalists purchase gyne-lotrimin 100mg overnight delivery, certified nurse–midwives, and certified midwives. Obstetricians and Pediatricians Credentialing and granting privileges to members of its medical staff are among the most important responsibilities of any health care facility. Other criteria for effec tive credentialing include review of official source data, such as the National 21 22 Guidelines for Perinatal Care Practitioner Data Bank, data from state licensing boards, data from other facili ties where the individual has privileges, and references from peers. The more difficult, yet critical, aspect of the credentialing process is the actual determination of which requested privileges should be granted. Problems can arise when physicians or staff perform procedures or use equipment for which they are not trained. For pediatric providers, the credentials required and the privileges extended will depend on the level of care that is provided. Laborists and Hospitalists the term “laborist” most commonly refers to an obstetrician–gynecologist who is employed by a hospital or physician group and whose primary role is to care for laboring patients and to manage obstetric emergencies. The term “hospital ist” refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Hospitalists help manage the continuum of patient care in the hospital, often seeing patients in the emergency department, follow ing them into the critical care unit, and organizing postacute care. An obstet ric–gynecologic hospitalist may provide in-house gynecologic services as well. Certified nurse–midwives and certified midwives manage the care of low-risk women in the antepartum, intrapartum, and postpartum periods; manage healthy newborns; and provide primary gynecologic services in accordance with state laws or regulations. In collaboration with obstetricians, certified nurse–midwives and certified mid wives also may be involved in the care of women with medical or obstetric complications. They work in a variety of settings, including private practice, community health facilities, clinics, hospitals, and accredited birth centers (see also Appendix E). This administrative approach requires close coordination and unified policy statements. This resuscitation should be per formed according to the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program. The team consists of obstetrician–gynecologists and other health care professionals who function within their educational preparation and scope of practice. A board-certified pediatrician with subspecialty certification in neonatal– perinatal medicine should be chief of the neonatal care service. These physi cians should coordinate the hospital’s perinatal care services and, in conjunction with other medical, anesthesia, nursing, midwifery, respiratory therapy, and hospital administration staff, develop policies concerning staffing, procedures, equipment, and supplies. Care of neonates at high risk should be provided by appropriately qualified personnel. When an infant is maintained on a ventilator, these specialized personnel should be available on site to manage respiratory emergencies. In collaboration with, or under the supervision of, a physician, care may be provided by quali fied advanced practice registered nurses who have completed a formal neonatal educational program and are certified by an accepted national body, such as the National Certification Corporation (see also “Perinatal Nurse Practitioners” later in this chapter). If they are in a regional center, they should devote their time to providing and supervising patient care services, research, and teaching, and they should coordinate the services provided at their hospital with those provided at institutions delivering lower levels of care in the region or system. Personnel qualified to manage the care of mothers or neonates with complex or critical illnesses, including emergencies, should be in-house. Pediatric surgical and anesthesia capability should be available onsite or at a closely related institution for consultation and care. Evidence indicates that management of neonates and young children by adult subspecialists, rather than pediatric subspecialists, results in greater costs, longer hospital stays, and potentially greater morbidity. Intrapartum care requires the same labor intensiveness and expertise as any other intensive care and, accordingly, perinatal units should have the same adequately trained personnel and fiscal support. The scope of practice should be based on national nursing guidelines for the specialty area of practice and should be in accordance with state laws and regulations and the recommended staffing patterns for the particular type of health care provider. The health care provider-to-patient ratio should take into account the role expected at the individual unit, acuity of patients, procedures performed, and participation in deliveries or neonatal transport. A multidisciplinary committee, including representatives from hospital, medical, and nursing administrations, should follow published professional guidelines, consult state nurse practice acts and any accompanying regulations, identify the types and numbers of procedures performed in each unit, delineate the direct and indirect nursing care activities performed, and identify the activities that are to be performed by non-nursing personnel. Advanced Practice Registered Nurses Trends in neonatal and maternal care have resulted in the increased use of advanced practice registered nurses. An advanced practice registered nurse is prepared, according to nationally recognized stan dards, by the completion of an educational program of study and supervised practice beyond the level of basic nursing. As of January 1, 2000, this prepara tion must include the attainment of a master’s degree in the nursing specialty. Nationally recognized certification examinations exist for each category of 28 Guidelines for Perinatal Care advanced practice nursing. Credentialing is now required on a national level and is no longer governed by individual states. The clinical nurse specialist models expert nursing practice, participates in admin istrative functions within the hospital setting, serves as a consultant external to the unit, and applies and promotes evidence-based nursing practice. A neonatal or women’s health nurse practitioner is a regis tered nurse who has clinical expertise in neonatal or women’s health nursing; has a master’s degree or has completed an educational program of study and supervised practice in the specialty; and has acquired supervised clinical experi ence in the management of patients and their families. Similar to the clinical nurse specialist, a nurse practitioner also may be involved in education, admin istration, consultation, and research. Women’s health nurse practitioners manage the care of women in collabo ration with a physician, usually an obstetrician–gynecologist or a maternal–fetal medicine specialist. They must demonstrate completion of a formal women’s Inpatient Perinatal Care ServicesCare of the Newborn 2929 health educational program and national certification as a women’s health nurse practitioner.