Chapter 13 Pregnancy at Risk: Pre-existing Cond. Test 1 Flashcards Preview

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Flashcards in Chapter 13 Pregnancy at Risk: Pre-existing Cond. Test 1 Deck (46):
1

The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function?

A. Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics
B. Prepare the woman for delivery by cesarean section since this is the recommended delivery method to sustain hemodynamics
C. Encourage the woman to avoid the use of narcotics or epidural regional analgesia since this alters cardiac function
D. Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling





A. The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor. A vaginal delivery is the preferred method of delivery for a woman with cardiac disease as it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

2

Maternal and neonatal risks associated with gestational diabetes mellitus are:

A. maternal premature rupture of membranes and neonatal sepsis.
B. maternal hyperemesis and neonatal low birth weight.
C. maternal preeclampsia and fetal macrosomia.
D. maternal placenta previa and fetal prematurity.

C. Premature rupture of membranes and neonatal sepsis are not risks associated with gestational diabetes. Hyperemesis is not seen with gestational diabetes, nor is there an association with low birth weight of the infant. Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia. Placental previa and subsequent prematurity of the neonate are not risks associated with gestational diabetes.

3

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:

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.


D. Although advanced maternal age may pose some health risks, for the woman with pregestational diabetes the most important factor remains the degree of glycemic control during pregnancy. The number of years since diagnosis is not as relevant to outcomes as the degree of glycemic control. The key to reducing risk in the pregestational diabetic woman is not the amount of insulin required but rather the level of glycemic control. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

4

Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for: (Select all that apply.)

A. miscarriage.
B. macrosomia.
C. gestational hypertension.
D. placental abruption.
E. stillbirth.

A. C. D. E.

Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Infants born to mothers with hypothyroidism are most likely to be of low birth weight or preterm. These outcomes can be improved with early diagnosis and treatment. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism. Placental abruption and stillbirth are risks associated with hypothyroidism.

5

A pregnant woman in her first trimester with a history of epilepsy is transported to the hospital via ambulance after suffering a seizure in a restaurant. The nurse expects which health care provider orders to be included in the plan of care? (Select all that apply.)

A. valproate (Depakote).
B. Serum lab levels of medications.
C. Abdominal ultrasounds.
D. Prenatal vitamins with vitamin D.
E. carbamazepine (Tegretol).

B. C. D.
Carbamazepine (Tegretol) and valproate (Depakote) should be avoided if possible during pregnancy, especially during the first trimester, because their use is associated with NTDs in the fetus. Checking lab levels of medications, performing abdominal ultrasounds to assess fetal growth, and taking prenatal vitamins with vitamin D are all expected interventions for a pregnant woman diagnosed with epilepsy.

6

A pregnant woman is being examined by the nurse in the outpatient obstetric clinic. The nurse suspects systemic lupus erythematosus (SLE) after revealing which symptoms? (Select all that apply.)

A. Muscle aches
B. Hyperactivity
C. Weight changes
D. Fever
E. Hypotension



A. C. D.

Fatigue, rather than hyperactivity is a common sign of SLE. Hypotension is not a characteristic sign of SLE. Common symptoms, including myalgias, fatigue, weight change, and fevers, occur in nearly all women with SLE at some time during the course of the disease. Although a diagnosis of SLE is suspected based on clinical signs and symptoms, it is confirmed by laboratory testing that demonstrates the presence of circulating autoantibodies. As is the case with other autoimmune diseases, SLE is characterized by a series of exacerbations (flares) and remissions (Chin and Branch, 2012).

7

During pregnancy, alcohol withdrawal may be treated using:

A. disulfiram (Antabuse).
B. corticosteroids.
C. benzodiazepines.
D. aminophylline.


C. benzodiazepines

Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids are not used to treat alcohol withdrawal. Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines. Aminophylline is not used to treat alcohol withdrawal.

8

Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?

A. Heroin
B. Alcohol
C. Phencyclidine palmitate (PCP)
D. Cocaine


A.
The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. Alcohol is not an opiate. PCP is not an opiate. Cocaine is not an opiate.

9

A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often:

A. orthopnea.
B. decreasing energy levels.
C. moist frequent cough and frothy sputum.
D. crackles (rales) at the bases of the lungs on auscultation.


B. decreasing energy levels.

Orthopnea is a finding that appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. A moist, frequent cough appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema.

10

From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks:

A. in the first trimester.
B. between 24 to 36 weeks of gestation.
C. during the last 4 weeks of pregnancy.
D. immediately postpartum.


B.
Women often have few symptoms of asthma during the first trimester. The severity of symptoms peaks between 24 and 36 weeks of gestation. Asthma appears to be associated with intrauterine growth restriction and preterm birth. During the last 4 weeks of pregnancy symptoms often subside. The period between 24 and 36 weeks of pregnancy is associated with the greatest severity of symptoms. Issues have often resolved by the time the woman delivers.

11

Thalassemia is a relatively common anemia in which:

A. an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs).
B. RBCs have a normal life span but are sickled in shape.
C. folate deficiency occurs.
D. there are inadequate levels of vitamin B12 .



A. an insufficient amount of hemoglobin is produced to fill the red blood cells.

Thalassemia is a hereditary disorder that involves the abnormal synthesis of the á or â chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs. This is the underlying description for sickle cell anemia. Folate deficiency is the most common cause of megaloblastic anemias during pregnancy. B12 deficiency must also be considered if the pregnant woman presents with anemia.

12

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:

A. euglycemia.
B. rheumatic fever.
C. pneumonia.
D. cardiac decompensation.


D. cardiac decompensation

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. Symptoms of cardiac decompensation may appear abruptly or gradually.

13

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that:

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 greater risk.

B. the most important cause of perinatal loss in diabetic pregnancy is congenital malformations.

Even with good control, sudden and unexplained stillbirth remains a major concern. Congenital malformations account for 30% to 50% of perinatal deaths. 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.

14

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that:

A. oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin.
B. dietary modifications and insulin are both required for adequate treatment.
C. glucose levels are monitored by testing urine 4r times a day and at bedtime.
D. dietary management involves distributing nutrient requirements over three meals and two or three snacks.

D. Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis.

15

A nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function?

A. Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics.
B. Prepare the woman for delivery by cesarean section because this is the recommended delivery method to sustain hemodynamics.
C. Encourage the woman to avoid the use of narcotics or epidural regional analgesia because this alters cardiac function.
D. Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling.

A. The side-lying position with the head and shoulders elevated helps facilitate hemodynamics during labor. A vaginal delivery is the preferred method for a woman with cardiac disease because it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. Epidural anesthesia for labor is preferred. (Easterling and Stout, 2012). Using the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

16

In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the client states:
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.”

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.

17

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with:
a. Frequent episodes of maternal hypoglycemia.
b. Congenital anomalies in the fetus.
c. Polyhydramnios.
d. Hyperemesis gravidarum.


B
Preconception counseling 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.

18

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:
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

D.
Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

19

In teaching the woman with pregestational diabetes about desired glucose levels, the nurse explains that a normal fasting glucose level, such as before breakfast, is in the range of _____ mg/dl.
a. 60 to 90 c. 120 to 150
b. 90 to 120 d. 150 to 180


A
Target glucose levels during a fasting period are 60 to 90 mg/dl. A glucose level of 90 to 120 mg/dl is consistent with expected levels at bedtime. A glucose level of 120 to 150 mg/dl is considered elevated for a fasting glucose level. A glucose level of 150 to 180 mg/dl is considered elevated for a fasting glucose level and indicates poor glycemic control.

20

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

A
Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor 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.

21

Congenital anomalies can occur with the use of antiepileptic drugs (AEDs), including (choose all that apply):
a. Cleft lip.
b. Congenital heart disease.
c. Neural tube defects.
d. Gastroschisis.
e. Diaphragmatic hernia.


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

22

Most women with gestational diabetes mellitus (GDM) develop type 2 diabetes in the postpartum period.

False

Most women with GDM return to normal glucose levels after childbirth.

23

Achieving and maintaining constant ____________________, with blood glucose levels in the range of 60 to 120 mg/dl, is the primary goal of medical therapy for the pregnant woman with diabetes. This is achieved through a combination of diet, insulin, exercise, and blood glucose monitoring.

Euglycemia

24

The most common neurologic disorder accompanying pregnancy is:
a. Eclampsia. c. Epilepsy.
b. Bell’s palsy. d. Multiple sclerosis.


C
The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic 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.

25

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 client with Marfan syndrome during labor, which intervention should the nurse complete first?
a. Antibiotic prophylaxis c. Surgery
b. -Blockers d. Regional anesthesia


A
Because of the potential for cardiac involvement during the third trimester and after birth, treatment with prophylactic antibiotics is highly recommended. -Blockers and restricted activity are recommended as treatment modalities earlier in the pregnancy. Regional anesthesia is well tolerated by clients with Marfan syndrome; however, it is not essential to care. Adequate labor 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.

26

With regard to anemia, nurses should be aware that:
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.


A
Combined with any other complication, anemia can result in congestive 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.

27

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that:
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.

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.

28

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 5 pounds 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

B
This client’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 client reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the client reports nervousness, based on the client’s other clinical symptoms the most appropriate nursing diagnosis would be imbalanced nutrition: less than body requirements.

29

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:
a. Euglycemia. c. Pneumonia.
b. Rheumatic fever. d. Cardiac decompensation.

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.

30

Nurses caring for antepartum women with cardiac conditions should be aware that:
a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor.
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.

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.

31

In caring for a pregnant woman with sickle cell anemia with increased blood viscosity, the nurse is concerned about the development of a thromboembolism. Nursing care would include:
a. Monitoring the client for a negative Homans’ sign.
b. Massaging her calves when the woman complains of pain.
c. Applying antiembolic stockings.
d. Maintaining a restriction on fluid intake.

C
Applying antiembolic stockings would be an appropriate nursing action. The nurse would monitor the client for Homans’ sign. 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.

32

Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to statistics, how often does cystic fibrosis occur in Caucasian live births?
a. 1 in 100 c. 1 in 2500
b. 1 in 1200 d. 1 in 3300

D.
Cystic fibrosis occurs in about 1 in 3300 Caucasian live births.

33

A woman with asthma is experiencing a postpartum hemorrhage. Which drug would NOT be used to treat her bleeding because it may exacerbate her asthma?
a. Pitocin
b. Nonsteroidal antiinflammatory drugs (NSAIDs)
c. Hemabate
d. Fentanyl

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

34

In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would:
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.

C
Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this client. 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.

35

With what heart condition is pregnancy not usually contraindicated?
a. Peripartum cardiomyopathy
b. Eisenmenger syndrome
c. Heart transplant
d. All of these contraindicate pregnancy.

C
Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation.

36

Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman has:
a. Valvular disease.
b. Congestive heart disease.
c. Arrhythmias
d. Postmyocardial infarction.

A
Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve stenosis. Prophylaxis for intrapartum endocarditis is not indicated for congestive heart disease, arrhythmias, or postmyocardial infarction.

37

A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding?
a. Hyperthyroidism c. Hypothyroidism
b. Phenylketonuria (PKU) d. Thyroid storm

B
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism.

38

While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease:
a. Is the same as that for any pregnant woman.
b. Includes rest, stool softeners, and monitoring of the effect of activity.
c. Includes ambulating frequently, alternating with active range of motion.
d. Includes limiting visits with the infant to once per day.

B
Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted 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 reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

39

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which are:
a. A regular heart rate and hypertension.
b. An increased urinary output, tachycardia, and dry cough.
c. Shortness of breath, bradycardia, and hypertension.
d. Dyspnea; crackles; and an irregular, weak pulse.



D
Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nail beds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation, but increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation, but bradycardia and hypertension would not.

40

An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life rather than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is:
a. Risk for injury to the fetus related to birth trauma.
b. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan.
c. Deficient knowledge related to insulin administration.
d. Risk for injury to the mother related to hypoglycemia or hyperglycemia.

B
Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have greater concern for changes to her social life than adoption of a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come much later in the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made and may not participate in the plan of care until understanding takes place.

41

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 one should the nurse tell her indicates a need for adjustment (insulin or sugar)?
a. 75 mg/dl before lunch; this is low, better eat now
b. 115 mg/dl 1 hour after lunch; this is a little high, maybe eat a little less next time
c. 115 mg/dl 2 hours after lunch; this is too high, time for insulin
d. 60 mg/dl just after waking up from a nap; this is too low, maybe eat a snack before going to sleep

D
60 mg/dl after waking from a nap is too low. During hours of sleep glucose levels should not be under 70 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dl. The readings 1 hour after a meal should be less than 130 mg/dl. Two hours after eating, the readings should be under 120 mg/dl.

42

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc:
a. Is now done for all pregnant women, not just those with or likely to have diabetes.
b. Is a snapshot of glucose control at the moment.
c. Would be considered evidence of good diabetes control with a result of 5% to 6%.
d. Is done on the patient’s urine, not her blood.

C
A score of 5% to 6% indicates good control. 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 the blood.

43

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that:
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 in any risk.

B
Congenital malformations account for 30% to 50% of perinatal deaths. 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.

44

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should know that:
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.

C
Pregnant women develop increased insulin resistance 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 (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.

45

In terms of the incidence and classification of diabetes, maternity nurses should know that:
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.

B
Type 2 often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2, sometimes called adult onset diabetes, is the 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.

46

Maternal phenylketonuria (PKU) is an important health concern during pregnancy because:
a. It is a recognized cause of preterm labor.
b. The fetus may develop neurologic problems.
c. A pregnant woman is more likely to die without dietary control.
d. Women with PKU are usually retarded and should not reproduce.


B
Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of uncertain etiology, or who have given birth to microcephalic infants.