Exam 2 — Labor and birth, fetal monitoring, analgesiaWeek 5
📚 Reading: ch. 12–13 — week split inferred
💡 The one idea
Folic acid works before conception, not after. The neural tube closes by about
week 4 — often before a pregnancy is even known.
🖼️ Iron deficiency anemia and pica.Swipe it sideways if it is cut off, or tap to open it full size.
⭐ The numbers to hold
Folic acid — 400 mcg daily for all women of
childbearing age; 4 mg if a previous neural tube defect
Extra calories — about +340 kcal in the 2nd trimester,
+450 in the 3rd. Not “eating for two”
Weight gain — 25–35 lb at a normal BMI
Iron — needs roughly double; take with vitamin C
🚨 Foods and substances to avoid
High-mercury fish — shark, swordfish, king mackerel, tilefish
Unpasteurized milk and soft cheese, deli meats — listeria
Raw or undercooked meat, fish and eggs
Cat litter and soil — toxoplasmosis
There is no known safe amount of alcohol in pregnancy. Fetal alcohol syndrome is entirely preventable and entirely permanent.
🧠 Normal discomforts and the honest fix
Complaint
Why
What actually helps
Morning sickness
hCG, first trimester
Dry crackers before rising; small frequent meals
Heartburn
Progesterone relaxes the sphincter
Small meals, upright after eating
Constipation
Slowed motility + iron
Fiber, fluids, walking
Leg cramps
Circulation, calcium
Dorsiflex the foot — do not point the toes
Backache
Shifted center of gravity
Pelvic tilt, low heels, side-lying
⚠️ Hyperemesis gravidarum is not morning sickness
Persistent vomiting with weight loss >5%, dehydration, ketonuria and electrolyte
imbalance. It needs IV fluids and admission, not dietary advice.
⭐ High-yield — what the exam actually asks
Show 5 moreHide these 5
Add roughly 300 kcal/day in pregnancy; about 500 kcal/day while lactating.
Weight gain, normal pre-pregnancy BMI: 25–35 lb.40 lb is excessive. 10 lb is inadequate and risks growth restriction. Weight loss only if medically supervised. BMI 25–29.9 → 15–25 lb; BMI under 18.5 → 35–45 lb.
Folic acid 400 mcg/day preconception and 600 mcg/day in pregnancy. Prevents neural tube defects — and it has to start before conception to work.
Iron ~27 mg/day, taken with orange juice. Vitamin C enhances absorption; milk and calcium inhibit it; an empty stomach worsens the nausea.
Pica — laundry starch, clay — means assess for iron-deficiency anemia. Do not normalize it and do not wait until delivery.
Show 3 moreHide these 3
Avoid: raw or undercooked fish and meat, high-mercury predatory fish, deli meats, unpasteurized soft cheeses (listeria, mercury, toxoplasmosis).
Exercise: 3 times weekly, 30 continuous minutes — 5 min warm-up, 20 active, 5 cool-down. Protein plus complex carbohydrate before; hydrate; no supine positions after the first trimester.
Teratogens: isotretinoin must be stopped — severe malformations during first-trimester organogenesis. Some psychiatric medications must be switched. Avoiding rubella exposure and stopping alcohol are correct behaviors.
Calories: NO increase in the first trimester, +340/day in the second, +450/day in the third. Lactation adds 340–400.
Weight gain for a normal BMI is 25–35 lb: about 1.1–4.4 lb across the whole first trimester, then roughly 1 lb/week.
Folic acid 400–800 mcg/day, ideally from 3 months preconception. It prevents neural tube defects — not anemia.
Iron 27 mg/day baseline, 60–120 mg elemental if deficient. Between meals with vitamin C; milk and caffeine block it; add a stool softener.
Calcium 1,000 mg/day — but 1,300 mg/day if she is under 19. Caffeine capped at 200 mg/day.
Show 5 moreHide these 5
Anemia thresholds in pregnancy: Hgb <11, Hct <33%, ferritin <10.
Maternal PKU: back on the low-phenylalanine diet at least 3 months before conception and throughout. Avoid aspartame. Untreated, the fetus sustains intellectual disability regardless of its own PKU status.
GDM targets: <95 fasting/premeal, <120 two hours postprandial. Diet and exercise first, insulin if that fails; most orals contraindicated, limited glyburide.
Live vaccines — rubella, varicella, MMR — are deferred to postpartum, then avoid pregnancy 4 weeks (rubella/MMR) or 1 month (varicella). Influenza, COVID-19 and Tdap are given during pregnancy.
Hyperemesis: urinalysis for ketones is the key initial test, and expect an elevated Hct from hemoconcentration. First-line is pyridoxine alone or with doxylamine — not an antiemetic.
📚 From your Maternal & Child textbook
Pillitteri, Maternal and Child Health Nursing — ch. 13 (nutrition) · ch. 22 (pregnancy with special needs).
Folic acid prevents neural tube defects, not anemia — and it has to be on board before conception to do it, which is why it is recommended from three months preconception.
⚠️ Exam traps
Folic acid started at the first prenatal visit is already late. The answer is preconception.
Iron with milk is the wrong answer every single time.
🧠 Mind maps 2
One per disorder, built from the structure of your ATI chapter.
ATI Active Learning Template — System DisorderPrenatal Care
Filled from ATI chapter 4, row by row from that chapter’s own sections — 12 of 12 rows have content.
7 rows came from outside your ATI chapter — 5 cite a source, 2 are built from this page’s own notes. Each one is labeled.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Prenatal care uses scheduled visits, screening, and education to catch problems early and reduce maternal-fetal illness and death; most birth defects arise between weeks 2 and 8. Visits address history, physical changes, and self-care teaching throughout pregnancy.
Health Promotion & Disease Prevention
Avoid all OTC drugs, supplements, and prescription meds unless the provider approves.
Avoid tobacco and alcohol; linked to anomalies, preterm birth, and growth restriction.
Encourage moderate exercise 30-45 min/day, about 150 min/week, unless contraindicated.
Avoid hot tubs and saunas during pregnancy.
Give influenza and COVID-19 vaccines per CDC guidance; give Tdap at 27-35 weeks gestation.
Emotional lability and ambivalence about the pregnancy are normal and often resolve by the third trimester.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Not in your ATI chapter — filled from NICHD.
Maternal age under 20 raises risk for pregnancy-related hypertension, anemia, preterm labor, and untreated sexually transmitted infections.
Pre-pregnancy conditions such as uncontrolled hypertension, diabetes, kidney disease, and autoimmune disorders increase pregnancy risk.
No amount of alcohol is considered safe during pregnancy, and marijuana or illegal drug use roughly doubles stillbirth risk.
NICHD · What are some factors that make a pregnancy high risk? · open the source →
Assessment — Expected Findings
From this module — built from the notes above on this page, not a section of the ATI chapter.
Fundal height in cm roughly equals gestational age in weeks from about 18–30 weeks.
Fetal heart rate 110–160/min.
Quickening at 16–20 weeks in a first pregnancy, earlier in later ones.
Blood pressure falls in the second trimester and returns to baseline by term — a rise is the abnormal finding.
Physiological anemia of pregnancy: plasma volume rises more than red cell mass, so hemoglobin dilutes.
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Indirect Coombs' test repeated at 24-28 weeks gestation for Rh-negative, unsensitized clients.
CBC with differential, Hgb, and Hct detect infection and anemia.
GBS vaginal/rectal culture obtained at 36 0/7 to 37 6/7 weeks gestation.
Urine culture recommended at 12-16 weeks gestation or at the first prenatal visit.
Diagnostic Procedures
Not in your ATI chapter — filled from USPSTF, 2019; StatPearls.
Rh(D) blood typing and antibody screening are done at the first prenatal visit for every pregnant patient.
If the biological father's Rh status is unknown, an unsensitized Rh-negative patient gets a repeat antibody check around week 24 to 28.
Group B strep culture is collected as a universal screen once the pregnancy reaches roughly the 36-week to 37 6/7-week mark.
Gestational diabetes screening is recommended for all pregnant patients at 24 weeks gestation or later.
USPSTF / StatPearls · Rh(D) Incompatibility: Screening; Gestational Diabetes: Screening; Group B Streptococcus and Pregnancy · open the source →
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Perform or assist with Leopold maneuvers to check fetal presentation and position.
Assist provider with the pelvic exam and pelvic measurements to gauge birth canal fit.
Have client empty bladder and breathe deeply during pelvic exam to ease discomfort.
Give Rho(D) immune globulin IM around 26-28 weeks gestation for Rh-negative clients.
Medications
Not in your ATI chapter — filled from USPSTF, 2019; StatPearls.
Unsensitized Rh-negative patients receive a 300 microgram dose of Rh immunoglobulin after 28-week antibody testing.
A second Rh immunoglobulin dose is given within 72 hours after birth if the newborn is Rh-positive.
Patients with a positive GBS culture receive intravenous penicillin in labor: a 5-million-unit loading dose, then 2.5 to 3 million units every 4 hours.
USPSTF / StatPearls · Rh(D) Incompatibility: Screening; Group B Streptococcus and Pregnancy · open the source →
Therapeutic Procedures
Not in your ATI chapter — filled from StatPearls, 2024.
Once a pregnancy reaches 15 weeks, amniocentesis becomes an option, done with a thin needle under constant ultrasound guidance.
During amniocentesis, about 18 to 20 mL of amniotic fluid is withdrawn after the first 1-2 mL is discarded.
In experienced hands, amniocentesis carries an estimated procedure-related pregnancy loss risk around 0.1% to 0.13%.
ATI Active Learning Template — System DisorderNutrition During Pregnancy
Filled from ATI chapter 5, row by row from that chapter’s own sections — 12 of 12 rows have content.
9 rows came from outside your ATI chapter — 3 cite a source, 6 are built from this page’s own notes. Each one is labeled.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Adequate nutrition during pregnancy supports maternal and fetal health. Normal-BMI clients should gain a total of about 25 to 35 lb (11.3 to 15.9 kg), spread across trimesters. Nurses assess diet history, weight trends, and labs like Hgb and iron, then plan postpartum nutrition.
Health Promotion & Disease Prevention
Not in your ATI chapter — filled from CDC; USPSTF, 2023.
Beginning folic acid at least 1 month before conception lowers the risk of fetal neural tube defects.
Heating deli meats and hot dogs until steaming, about 165°F, reduces listeria exposure during pregnancy.
Avoiding unpasteurized soft cheeses, such as brie or queso fresco, and raw sprouts further reduces foodborne illness risk.
For a normal pre-pregnancy BMI, a total gain of 25 to 35 pounds is the CDC-recommended target.
For a pre-pregnancy BMI in the obese range, the CDC-recommended total gain is only 11 to 20 pounds.
CDC / USPSTF · Safer Food Choices for Pregnant Women; Weight Gain During Pregnancy; Folic Acid Supplementation to Prevent Neural Tube Defects · open the source →
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Age, culture, education, and socioeconomic status can limit adequate nutrition in pregnancy.
Adolescents may have poor eating habits and struggle to stay adherent with iron supplements.
Vegetarian diets may run low in protein, calcium, iron, zinc, and vitamin B12.
Nausea and vomiting during pregnancy can reduce intake.
Anemia is a nutrition-related risk factor.
Eating disorders such as anorexia nervosa and bulimia nervosa affect nutrition status.
Pica (craving nonfood items like dirt or clay) can crowd out nutritious food intake.
Limited ability to purchase or access food is a risk factor.
Assessment — Expected Findings
From this module — built from the notes above on this page, not a section of the ATI chapter.
Weight gain by pre-pregnancy BMI — underweight 28–40 lb, normal 25–35, overweight 15–25, obese 11–20.
Pattern matters as much as total: about 1–4 lb in the first trimester, then roughly 1 lb a week.
Energy need rises by roughly 340 kcal in the second trimester and 450 in the third — not “eating for two”.
Sudden weight gain with edema is a preeclampsia sign, not a nutrition finding.
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
From this module — built from the notes above on this page, not a section of the ATI chapter.
Hemoglobin and hematocrit at the first visit and again around 28 weeks.
Anemia in pregnancy is generally Hgb below about 11 g/dL in the first and third trimesters.
Ferritin if iron deficiency is suspected.
1-hour glucose challenge at 24–28 weeks; ≥140 mg/dL goes on to the 3-hour test.
Vitamin D and B12 where diet or malabsorption suggests it.
Diagnostic Procedures
From this module — built from the notes above on this page, not a section of the ATI chapter.
No imaging is part of nutritional assessment — it is history, diet recall and measurement.
Serial fundal height that lags may be the first sign of poor growth.
Ultrasound for estimated fetal weight if growth restriction is suspected.
24-hour diet recall or a food diary is the most useful single tool.
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
From this module — built from the notes above on this page, not a section of the ATI chapter.
Ask what she actually eats before teaching what she should — and ask whether she can afford and store it.
Iron with vitamin C; not with milk, tea, coffee or antacids, which block absorption.
Warn that iron causes dark stools and constipation, so it is not stopped by surprise.
For nausea: small frequent meals, dry carbohydrate before rising, fluids between rather than with meals.
Screen for pica directly — it is common, under-reported, and associated with iron deficiency.
Medications
Not in your ATI chapter — filled from USPSTF, 2023.
USPSTF grades daily folic acid supplementation of 400 to 800 mcg as an 'A' recommendation for anyone who could become pregnant.
Folic acid supplementation should continue through the first 2 to 3 months of pregnancy, not stop at conception.
U.S. Preventive Services Task Force · Folic Acid Supplementation to Prevent Neural Tube Defects: Preventive Medication · open the source →
Therapeutic Procedures
From this module — built from the notes above on this page, not a section of the ATI chapter.
Referral to WIC or equivalent food assistance.
Dietitian consultation for diabetes, multiple gestation, bariatric surgery history, or a restricted diet.
Hyperemesis gravidarum may need IV fluids, electrolyte correction and antiemetics.
Enteral or parenteral nutrition only in severe, persistent cases.
💬 Around the patientClient Education · Interprofessional Care
Client Education
No added calories needed in first trimester; add about 340 cal/day in second and 450 cal/day in third trimester (BMI 18.5-24.9).
Well-nourished breastfeeding clients need roughly 340-400 extra calories/day.
Folic acid400-800 mcg/day for 3 months preconception and continued through pregnancy prevents neural tube defects.
Iron absorbs best between meals with vitamin C; milk and caffeine block absorption; a stool softener may be needed.
Calcium target: 1,000 mg/day for ages 19-50, 1,300 mg/day if under 19.
Fluid goal: 8-10 glasses (about 2.3 L) of water daily.
Limit caffeine to 200 mg/day; excess linked to infertility, miscarriage, or IUGR.
Interprofessional Care
From this module — built from the notes above on this page, not a section of the ATI chapter.
Registered dietitian — the central referral for this chapter.
Social worker for food insecurity, which changes what any advice is worth.
Diabetes educator for gestational diabetes.
Lactation consultant — nutrition planning continues into breastfeeding.
⚠️ What goes wrongComplications
Complications
Not in your ATI chapter — filled from CDC; Kirchengast et al., 2024.
Pregnant women are about 10 times more likely than the general population to develop a listeria infection.
In underweight, normal-weight, and overweight women, gaining more than the IOM-recommended amount was linked to significantly higher macrosomia and emergency cesarean rates.
In obese women, excessive gestational weight gain increased birth weight but was not linked to significantly higher macrosomia or cesarean risk in this study.
CDC; International Journal of Environmental Research and Public Health · Safer Food Choices for Pregnant Women; The Impact of Higher Than Recommended Gestational Weight Gain on Fetal Growth and Perinatal Risk Factors—The IOM Criteria Reconsidered · open the source →
📋 Medical Conditions6 parts
ATI Active Learning Template — System DisorderMedical Conditions
Filled from ATI chapter 9, row by row from that chapter’s own sections — 12 of 12 rows have content.
3 rows came from outside your ATI chapter — 3 cite a source, 0 are built from this page’s own notes. Each one is labeled.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
This chapter reviews pregnancy complications beyond bleeding: cervical insufficiency, hyperemesis gravidarum, iron-deficiency anemia, gestational diabetes, and gestational hypertensive disorders—covering risk factors, key labs, medications, and nursing priorities needed to protect mother and fetus.
Health Promotion & Disease Prevention
Not in your ATI chapter — filled from StatPearls, 2024.
For pregestational diabetes, achieving an A1C below 6.5% before conception is the American Diabetes Association's recommended target.
No clearly safe A1C threshold exists; congenital anomaly risk rises progressively as preconception glycemic control worsens.
At an A1C around 10%, congenital anomaly rates run about 10%; near an A1C of 13%, rates climb to about 20%.
Preconception glycemic surveillance is considered the most effective way to prevent diabetic embryopathy.
StatPearls (NCBI Bookshelf) · Diabetic Embryopathy · open the source →
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
In-utero DES exposure (banned after 1971) raises cervical insufficiency risk
A history of cervical trauma or an early pregnancy loss raises insufficiency risk
Multifetal gestation and gestational trophoblastic disease raise hyperemesis risk
A history of migraines or family hyperemesis raises risk of recurrence
Type 1 diabetes and hyperthyroidism raise hyperemesis risk
A short gap between pregnancies or heavy pre-pregnancy menses raises anemia risk
Obesity and maternal age over 25 years raise GDM risk
A prior macrosomic infant or prior GDM raises the risk of recurrence
Assessment — Expected Findings
Cervical insufficiency: pelvic pressure or urge to push, often with painless dilation
Cervical insufficiency: ultrasound shows a cervix under 25 mm, funneling, or effacement
Cerclage is typically placed around 13 to 14 weeks and removed at 36 to 37 weeks
Hyperemesis: prolonged vomiting with dehydration, weight loss, and electrolyte imbalance
Hyperemesis: increased pulse, decreased BP, poor skin turgor from fluid loss
Iron-deficiency anemia: fatigue, tachycardia, dizziness, shortness of breath, and pica
GDM findings are often subtle and picked up only through lab screening
GDM, when symptomatic: increased thirst, urination, fatigue, nausea, blurred vision
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
Hyperemesis: urine ketones/acetones is the key initial test; specific gravity is elevated
Hyperemesis: sodium, potassium, and calcium drop; metabolic acidosis or alkalosis can occur
Hyperemesis: CBC shows an elevated Hct from hemoconcentration
Anemia is diagnosed with Hgb under 11 mg/dL
Anemia is diagnosed with Hct under 33.0%
Diagnostic Procedures
GDM: nonstress test checks fetal well-being; biophysical profile if the NST is nonreactive
GDM: amniocentesis can check amniotic fluid phosphatidylglycerol for fetal lung maturity
Preeclampsia: urine dipstick and a 24-hr collection assess proteinuria
Preeclampsia fetal status can be tracked with an NST, contraction stress test, BPP, or repeat ultrasounds
Doppler flow studies and daily kick counts also monitor fetal status in preeclampsia
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Cervical insufficiency: watch for contractions, ROM, or infection signs after cerclage placement
Hyperemesis: track intake/output, skin turgor, vital signs, and daily weight
Iron-deficiency anemia: recommended intake is 27 mg/day; prenatal vitamins have about 30 mg
If iron-deficient, dosing increases to 60 to 120 mg/day elemental iron
GDM: monitor maternal blood glucose and fetal status closely
Preeclampsia: use a properly sized cuff and avoid talking during BP checks
Preeclampsia: encourage side-lying positioning and perform NST/daily kick counts
Magnesium sulfate must run through an infusion control device for an accurate rate
Monitor reflexes, LOC, respiratory rate, and urine output (indwelling catheter) during mag sulfate therapy
Medications
Hyperemesis: IV fluids for hydration are the first priority
Hyperemesis: pyridoxine (B6) alone or with doxylamine is first-line and ACOG-recommended
Hyperemesis: antiemetics are used cautiously; corticosteroids are reserved for refractory cases
GDM is managed first with diet and exercise; insulin is added if glucose stays high
Glyburide is a limited oral option for GDM; most oral agents are contraindicated
Low-dose aspirin starts late in the first trimester for a history of early-onset preeclampsia
Antihypertensives used include methyldopa, nifedipine, hydralazine, and labetalol
Avoid ACE inhibitors and ARBs for hypertension in pregnancy
Therapeutic Procedures
Not in your ATI chapter — filled from StatPearls, 2024.
Maternal echocardiography helps evaluate structural and functional cardiac status in pregnant patients with known or suspected heart disease.
A 12-lead ECG and maternal BNP level are used alongside CBC and CMP to assess cardiac disease severity in pregnancy.
StatPearls (NCBI Bookshelf) · Cardiac Disease in Pregnancy · open the source →
💬 Around the patientClient Education · Interprofessional Care
Client Education
Hyperemesis: avoid known triggers like specific odors
Hyperemesis: start with bland foods (dry toast, crackers, rice) and advance as tolerated
Severe hyperemesis may require enteral tube feeding or TPN
Take iron supplements on an empty stomach with orange juice to boost absorption
Pair an iron-rich diet with vitamin C foods; add fiber and fluids for constipation
GDM: perform daily kick counts and self-monitor blood glucose
GDM: follow a carb-restricted diabetic diet with dietitian guidance and regular exercise
Interprofessional Care
Not in your ATI chapter — filled from StatPearls, 2024.
Pregnancy with cardiac disease requires coordinated care among high-risk obstetricians, cardiologists, and perinatologists.
Pharmacists play a distinct role in managing cardiac medications during pregnancy since many drugs can harm the fetus.
Nurses are highlighted for their role in early recognition of worsening cardiac disease states in pregnant patients.
StatPearls (NCBI Bookshelf) · Cardiac Disease in Pregnancy · open the source →
The lines from this module that carry a number, a dose or an absolute rule — the ones that decide questions. Everything else is on the cards above.
Add roughly 300 kcal/day in pregnancy; about 500 kcal/day while lactating.
Weight gain, normal pre-pregnancy BMI: 25–35 lb.40 lb is excessive. 10 lb is inadequate and risks growth restriction. Weight loss only if medically supervised. BMI 25–29.9 → 15–25 lb; BMI under 18.5 → 35–45 lb.
Folic acid 400 mcg/day preconception and 600 mcg/day in pregnancy. Prevents neural tube defects — and it has to start before conception to work.
Iron ~27 mg/day, taken with orange juice. Vitamin C enhances absorption; milk and calcium inhibit it; an empty stomach worsens the nausea.
Pica — laundry starch, clay — means assess for iron-deficiency anemia. Do not normalize it and do not wait until delivery.
Exercise: 3 times weekly, 30 continuous minutes — 5 min warm-up, 20 active, 5 cool-down. Protein plus complex carbohydrate before; hydrate; no supine positions after the first trimester.
Teratogens: isotretinoin must be stopped — severe malformations during first-trimester organogenesis. Some psychiatric medications must be switched. Avoiding rubella exposure and stopping alcohol are correct behaviors.
Calories: NO increase in the first trimester, +340/day in the second, +450/day in the third. Lactation adds 340–400.
Weight gain for a normal BMI is 25–35 lb: about 1.1–4.4 lb across the whole first trimester, then roughly 1 lb/week.
Folic acid 400–800 mcg/day, ideally from 3 months preconception. It prevents neural tube defects — not anemia.
Iron 27 mg/day baseline, 60–120 mg elemental if deficient. Between meals with vitamin C; milk and caffeine block it; add a stool softener.
Calcium 1,000 mg/day — but 1,300 mg/day if she is under 19. Caffeine capped at 200 mg/day.
Anemia thresholds in pregnancy: Hgb <11, Hct <33%, ferritin <10.
Maternal PKU: back on the low-phenylalanine diet at least 3 months before conception and throughout. Avoid aspartame. Untreated, the fetus sustains intellectual disability regardless of its own PKU status.
🎯 Module quiz
Questions for this module. They also feed the Mega Quiz.
