Chapter 14

Question 1

In assessing the knowledge of a pregestational woman with type 1 diabetes about changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the patient states which of the following?

a. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
b. “Insulin dosage will likely need to be increased during the second and third trimesters.”
c. “Episodes of hypoglycemia are more likely to occur during the first 3 months.”
d. “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding.”

Answer 1

ANS: A
Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. “Insulin dosage will likely need to be increased during the second and third trimesters,” “Episodes of hypoglycemia are more likely to occur during the first 3 months,” and “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding” are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy.

Question 2

Preconception counselling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with which of the following?

a. Frequent episodes of maternal hypoglycemia
b. Congenital anomalies in the fetus
c. Polyhydramnios
d. Hyperemesis gravidarum

Answer 2

ANS: B
Preconception counselling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events as the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.

Question 3

In planning for the care of a 30-year-old woman with pregestational diabetes, what does the nurse recognize as the most important factor affecting pregnancy outcome?

a. Mother’s age
b. Number of years since diabetes was diagnosed
c. Amount of insulin required prenatally
d. Degree of glycemic control during pregnancy

Answer 3

ANS: D
Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. The mother`s age is not related to gestational diabetes. Number of years since diabetes was diagnosed is not the most important factor affecting pregnancy outcome. The amount of insulin required prenatally is not the most important factor affecting pregnancy outcome.

Question 4

What normal fasting glucose level should the nurse recommend for a woman with pregestational diabetes?

a. 2.5–3.5 mmol/L
b. 3.8–5.2 mmol/L
c. 5.5–7.7 mmol/L
d. 5.0–6.6 mmol/L

Answer 4

ANS: B
Target glucose levels during a fasting period are 3.8–5.2 mmol/L. A glucose level of 2.5–3.5 mmol/L is low. A glucose level of 5.5–7.7 mmol/L is consistent with expected levels with 1-hour postprandial plasma glucose (PG). A glucose level of 5.0–6.6 mmol/L is considered normal for a 2-hour postprandial PG.

Question 5

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for which of the following?

a. Macrosomia
b. Congenital anomalies of the central nervous system
c. Preterm birth
d. Low birth weight

Answer 5

ANS: A
Fetal macrosomia is a risk to the fetus of a mother with GDM. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labour or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.

Question 6

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 2 kilograms less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time?

a. Deficient fluid volume
b. Imbalanced nutrition: less than body requirements
c. Imbalanced nutrition: more than body requirements
d. Disturbed sleep pattern

Answer 6

ANS: B
This patient’s clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This patient reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the patient reports nervousness, based on the patient’s other clinical symptoms the most appropriate nursing diagnosis would be imbalanced nutrition: less than body requirements.

Question 7

Which of the following should the nurse know about drug testing during pregnancy in Canada?
a. It is required at the first prenatal visit.
b. Only those drugs disclosed by the woman are tested for.
c. There is no legal requirement to test the mother or the
newborn child.
d. Testing is required before labour and delivery.

Answer 7

ANS: C
There is no legal requirement in Canada for a health care provider to test either the mother or the newborn child for the presence of drugs. Testing is not required on the initial prenatal visit. If testing were to occur, all substances would be tested for, not just those disclosed by the mother. Testing is not required before labour and delivery.

Question 8

Which of the following should the nurse know in terms of the incidence and classification of diabetes?

a. Type 1 diabetes is most common.
b. Type 2 diabetes often goes undiagnosed.
c. Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth.
d. Type 1 diabetes may become type 2 during pregnancy.

Answer 8

ANS: B
Type 2 diabetes often goes undiagnosed for many years because hyperglycemia develops gradually and often is not severe. Type 2, sometimes called adult-onset diabetes, is most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between types 1 and 2 diabetes.

Question 9

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Which of the following is important for the nurse to know?

a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own.
b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar.
c. During the second and third trimesters pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.
d. Maternal insulin requirements steadily decline during pregnancy.

Answer 9

ANS: C
Pregnant women develop increased insulin resistance during the second and third trimesters. Pregnancy exerts a diabetogenic effect on the maternal metabolic status during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia. Maternal insulin requirements may double or quadruple by the end of pregnancy

Question 10

With regard to maternal diabetes and other risk situations affecting the mother and fetus, what should the nurse should be aware of?

a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
b. Hydramnios occurs approximately twice as often in diabetic pregnancies.
c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies.
d. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.

Answer 10

ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

Question 11

The nurse should be aware of which of the following in relation to diabetes in pregnancy?

a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern.
b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations.
c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring.
d. At birth the neonate of a diabetic mother is no longer at any risk.

Answer 11

ANS: B
Congenital malformations account for 6% to 10% of infants born to mothers with diabetes. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

Question 12

The nurse providing care for a woman with gestational diabetes understands which of the following about a laboratory test for glycosylated hemoglobin Alc?

a. The test is now done for all pregnant women, not just those with or likely to have diabetes.
b. The test is a snapshot of glucose control at the moment.
c. The test is completed to evaluate glycemic control over time.
d. The test is done on the patient’s urine, not her blood.

Answer 12

ANS: C
A laboratory test for glycosylated hemoglobin Alc would provide evidence of glycemic control over time. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on blood, not urine.

Question 13

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which reading should the nurse tell her is not within the normal limits for blood glucose levels?

a. 3.2 mmol/L
b. 3.8 mmol/L
c. 4.2 mmol/L
d. 4.8 mmol/L

Answer 13

ANS: A
Normal glucose levels during pregnancy are 3.8–5.2 mmol/L; therefore, the only reading that is not within normal limits is 3.2 mmol/L.

Question 14

Which factor increases the risk of mother-to-child perinatal HIV transmission?

a. Treatment with antiretroviral
b. Presence of chorioamnionitis
c. Bottle feeding after delivery
d. Maternal plasma viral level less than 1000 copies per mL

Answer 14

ANS: B
The presence of chorioamnionitis is a factor that increases the risk of transmission. Treatment will antiretroviral medication decreases the risk. Breastfeeding, not bottle feeding, increases the risk. A maternal plasma viral level greater than 1000 copies per mL not less than this, increases the risk.

Question 15

Which of the following statements is accurate in providing perinatal care for women who use substances?

a. A decision to stop using substances must be made by the family.
b. Harm reduction practices are not effective with pregnant women.
c. Effects of perinatal substance use in pregnancy and postpartum must be reviewed.
d. Use of community resources for women to eliminate a social bias for perinatal care must be avoided.

Answer 15

ANS: C
Reviewing effects of perinatal substance use in pregnancy and postpartum is one recommendation for perinatal care for women who use substances. The decision to stop using substances must be the woman’s, not her family’s. Harm-reduction practices are effective with all individuals that use substances. Community resources should not be avoided, rather the nurse should be familiar with what is available.

Question 16

The nurse must be alert for which signs and symptoms of cardiac decompensation when caring for a pregnant woman with cardiac problems?

a. A regular heart rate and hypertension
b. An increased urinary output, tachycardia, and dry cough
c. Shortness of breath, bradycardia, and hypertension
d. Shortness of breath; crackles; and an irregular, weak pulse

Answer 16

ANS: D
Signs of cardiac decompensation include crackles; an irregular, weak, rapid pulse; generalized edema; and shortness of breath. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation; increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation; bradycardia and hypertension would not.

Question 17

A woman has presented at the prenatal clinic with a previous history of rheumatic heart disease. Prophylaxis treatment of subacute bacterial endocarditis is given before and after birth when a pregnant woman has which of the following?

a. Valvular disease
b. Congestive heart disease
c. Arrhythmias
d. Postmyocardial infarction

Answer 17

ANS: A
Prophylaxis for valvular disease is given to prevent infective endocarditis, as this woman is at high risk because of her history of rheumatic heart disease. Prophylaxis for intrapartum endocarditis is not indicated for congestive heart disease, arrhythmias, or postmyocardial infarction

Question 18

While providing care in an obstetrical setting, the nurse should understand that postpartum care of the woman with cardiac disease should include which of the following?

a. It should be the same as that for any pregnant woman.
b. It includes rest, stool softeners, and monitoring of the effect of activity.
c. It includes ambulating frequently, alternating with active range of motion.
d. It includes limiting visits with the infant to once per day.

Answer 18

ANS: B
When providing care for a pregnant woman with cardiac disease, bed rest may be ordered with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the postpartum period is tailored to the woman’s functional capacity. The woman will be on bed rest to conserve energy and to reduce strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated

Question 19

A woman with asthma is experiencing a postpartum hemorrhage. Which drug would be recommended to treat her bleeding that would not exacerbate her asthma?

a. Oxytocin
b. Nonsteroidal anti-inflammatory drugs (NSAIDs)
c. Hemabate
d. Fentanyl

Answer 19

ANS: A
Oxytocin would be the drug of choice to treat this woman’s bleeding, because it would not exacerbate her asthma. Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding.

Question 20

In providing nutritional counselling for the pregnant woman experiencing cholecystitis, the nurse should include which of the following?

a. Assess the woman’s dietary history for adequate calories and proteins.
b. Instruct the woman that the bulk of calories should come from proteins.
c. Instruct the woman to eat a low-fat diet and avoid fried foods.
d. Instruct the woman to eat a low-cholesterol, low-salt diet.

Answer 20

ANS: C
Instructing the woman to eat a low-fat diet and to avoid fried foods is appropriate nutritional counselling for this patient. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated.

Question 21

In caring for a pregnant woman with sickle cell anemia with increased blood viscosity, the nurse is concerned about the development of a thromboembolism. Which of the following would be important to include in nursing care?

a. Monitor the patient for loss of deep tendon reflexes.
b. Massage her calves when the woman complains of pain.
c. Apply antiembolic stockings.
d. Maintain a restriction on fluid intake.

Answer 21

ANS: C
Applying antiembolic stockings would be an appropriate nursing action. Loss of deep tendon reflexes would be related to pre-eclampsia, not sickle cell anemia. Massaging the calves is not appropriate because this may dislodge a thromboembolism into the bloodstream (if one is present). Appropriate nursing care would include maintaining adequate hydration, not restricting fluid intake

Question 22

Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counselling for couples regarding carrier status. According to statistics, cystic fibrosis occurs once in how many White live births?

a. 100
b. 1200
c. 2500
d. 3300

Answer 22

ANS: D

Cystic fibrosis occurs in about 1 in 3300 White live births.

Question 23

With which of following heart conditions is pregnancy usually contraindicated?

a. Pre-existing hypertension
b. Eisenmenger syndrome
c. Heart transplant
d. Aortic valve stenosis

Answer 23

ANS: B
Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. Pre-existing hypertension is not a contraindication for pregnancy. Aortic valve stenosis is not a contraindication for pregnancy

Question 24

During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. The nurse knows that these are most likely signs of which of the following conditions?

a. Euglycemia
b. Rheumatic fever
c. Pneumonia
d. Cardiac decompensation

Answer 24

ANS: D
Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation.

Question 25

What should the nurse caring for antepartum women with cardiac conditions be aware of?

a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labour.
b. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms.
c. Women with class III cardiac disease should get 8 to 10 hours of sleep every day and limit housework, shopping, and exercise.
d. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

Answer 25

ANS: B
Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can carry on limited normal activities with discretion, although they still need a good amount of sleep.

Question 26

What should nurses be aware of with regard to anemia?

a. It is the most common medical disorder of pregnancy.
b. It can trigger reflex brachycardia.
c. The most common form of anemia is caused by folate deficiency.
d. Thalassemia is a European version of sickle cell anemia.

Answer 26

ANS: A
Anemia is the most common medical disorder of pregnancy. Combined with any other complication, anemia can result in heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.

Question 27

What is the most common neurological disorder accompanying pregnancy?

a. Eclampsia
b. Bell’s palsy
c. Epilepsy
d. Multiple sclerosis

Answer 27

ANS: C
The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurological disorder accompanying pregnancy. Bell’s palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth.

Question 28

Marfan syndrome is an autosomal dominant genetic disorder that displays as weakness of the connective tissue, joint deformities, ocular dislocation, and weakness to the aortic wall and root. While providing care to a patient with Marfan syndrome early in her pregnancy, which intervention should the nurse initially anticipate?

a. Antibiotic prophylaxis
b. β-Blockers
c. Surgery
d. Regional anaesthesia

Answer 28

ANS: B
Antibiotic prophylaxis is not a form of therapy indicated for Marfan syndrome. β-Blockers and restricted activity are recommended as treatment modalities earlier in the pregnancy. Regional anaesthesia is well tolerated by patients with Marfan syndrome; however, it is not essential to care. Adequate labour support may be all that is necessary if an epidural is not part of the woman’s birth plan. Surgery for cardiovascular changes such as mitral valve prolapse, aortic regurgitation, root dilation, or dissection may be necessary. Mortality rates may be as high as 50% in women who have severe cardiac disease.

Question 29

Which one of the following congenital anomalies may occur with the use of antiepileptic drugs (AEDs)?

a. Gastroschisis
b. Congenital heart disease
c. Diaphragmatic hernia
d. Intrauterine growth restriction

Answer 29

ANS: B
Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis, intrauterine growth restriction, and diaphragmatic hernia are not associated with the use of AEDs.