Flashcards in Chapter 29 Deck (31):
1. Preconception counseling is critical in the safe management of diabetic pregnancies. Which complication is commonly associated with poor glycemic control before and during early pregnancy?
a. Frequent episodes of maternal hypoglycemia
b. Congenital anomalies in the fetus
d. Hyperemesis gravidarum
Preconception counseling is particularly important since strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risk of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormonal changes and the effects on insulin production and use. Hydramnios occurs approximately 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is observed in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.
2. During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective?
a. “I will need to eat 600 more calories per day because I am pregnant.”
b. “I can continue with the same diet as before pregnancy as long as it is well balanced.”
c. “Diet and insulin needs change during pregnancy.”
d. “I will plan my diet based on the results of urine glucose testing.”
Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Dietary management during a diabetic pregnancy must be based on blood, not urine, glucose changes.
3. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition?
b. Congenital anomalies of the central nervous system
c. Preterm birth
d. Low birth weight
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 fetus.
4. 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. Which nursing diagnosis is most appropriate for the client 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
This client’s clinical cues include weight loss, which supports a nursing diagnosis of “Imbalanced nutrition: less than body requirements.” No clinical signs or symptoms support a nursing diagnosis of deficient fluid volume. This client reports weight loss, not weight gain. Although the client reports nervousness, the most appropriate nursing diagnosis, based on the client’s other clinical symptoms, is “Imbalanced nutrition: less than body requirements.”
5. A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy?
a. PKU is a recognized cause of preterm labor.
b. The fetus may develop neurologic problems.
c. A pregnant woman is more likely to die without strict dietary control.
d. Women with PKU are usually mentally handicapped and should not reproduce.
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 an uncertain cause, or who have given birth to microcephalic infants.
6. The nurse who is caring for a woman hospitalized for hyperemesis gravidarum would expect the initial treatment to involve what?
a. Corticosteroids to reduce inflammation
b. Intravenous (IV) therapy to correct fluid and electrolyte imbalances
c. Antiemetic medication, such as pyridoxine, to control nausea and vomiting
d. Enteral nutrition to correct nutritional deficits
Initially, the woman who is unable to down clear liquids by mouth requires IV therapy to correct fluid and electrolyte imbalances. Corticosteroids have been successfully used to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic medication. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation but is not the initial treatment for this client.
7. In terms of the incidence and classification of diabetes, which information should the nurse keep in mind when evaluating clients during their ongoing prenatal appointments?
a. Type 1 diabetes is most common.
b. Type 2 diabetes often goes undiagnosed.
c. GDM means that the woman will receive insulin treatment until 6 weeks after birth.
d. Type 1 diabetes may become type 2 during pregnancy.
Type 2 diabetes often goes undiagnosed because hyperglycemia gradually develops and is often not severe. Type 2, sometimes called adult-onset diabetes, is the most common type of diabetes. 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 type 1 and type 2 diabetes.
8. A number of metabolic changes occur throughout pregnancy. Which physiologic adaptation of pregnancy will influence the nurse’s plan of care?
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.
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 10th 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.
9. Which statement concerning the complication of maternal diabetes is the most accurate?
a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
b. Hydramnios occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregnancies.
c. Infections occur about as often and are considered about as serious in both diabetic and nondiabetic pregnancies.
d. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.
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.
10. Which statement regarding the laboratory test for glycosylated hemoglobin Alc is correct?
a. The laboratory test for glycosylated hemoglobin Alc is performed for all pregnant women, not only those with or likely to have diabetes.
b. This laboratory test is a snapshot of glucose control at the moment.
c. This laboratory test measures the levels of hemoglobin Alc, which should remain at less than 7%.
d. This laboratory test is performed on the woman’s urine, not her blood.
Hemoglobin Alc levels greater than 7% indicate an elevated glucose level during the previous 4 to 6 weeks. This extra laboratory test is for diabetic women and defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are performed on the blood.
11. A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding?
d. Thyroid storm
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and therefore should elect not to breastfeed. A woman with either hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding.
12. 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 than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. What is the most appropriate diagnosis at this time?
a. Risk for injury, to the fetus related to birth trauma
b. Deficient knowledge, related to diabetic pregnancy management
c. Deficient knowledge, related to insulin administration
d. Risk for injury, to the mother related to hypoglycemia or hyperglycemia
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 more concerned about changes to her social life than adopting a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come 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.
13. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?
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; it is time for insulin.
d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.
14. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth, and large amounts of bilirubin are released into the neonate’s circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, hyperinsulinemia develops in the neonate.
15. Which preexisting factor is known to increase the risk of GDM?
a. Underweight before pregnancy
b. Maternal age younger than 25 years
c. Previous birth of large infant
d. Previous diagnosis of type 2 diabetes mellitus
A previous birth of a large infant suggests GDM. Obesity (body mass index [BMI] of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years is not generally at risk for GDM. The person with type 2 diabetes mellitus already has diabetes and thus will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
16. Which physiologic alteration of pregnancy most significantly affects glucose metabolism?
a. Pancreatic function in the islets of Langerhans is affected by pregnancy.
b. Pregnant women use glucose at a more rapid rate than nonpregnant women.
c. Pregnant women significantly increase their dietary intake.
d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.
Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.
17. To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet?
a. Eat six small equal meals per day.
b. Reduce the carbohydrates in her diet.
c. Eat her meals and snacks on a fixed schedule.
d. Increase her consumption of protein.
Having a fixed meal schedule will provide the woman and the fetus with a steady blood sugar level, provide a good balance with insulin administration, and help prevent complications. Having a fixed meal schedule is more important than the equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.
1. A serious but uncommon complication of undiagnosed or partially treated hyperthyroidism is a thyroid storm, which may occur in response to stress such as infection, birth, or surgery. What are the signs and symptoms of this emergency disorder? (Select all that apply.)
ANS: A, C
Fever, restlessness, tachycardia, vomiting, hypotension, and stupor are symptoms of a thyroid storm. Fever, not hypothermia; tachycardia, not bradycardia; and hypotension, not hypertension, are symptoms of thyroid storm.
2. Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Because severe hypothyroidism is associated with infertility and miscarriage, it is not often seen in pregnancy. Regardless of this fact, the nurse should be aware of the characteristic symptoms of hypothyroidism. Which do they include? (Select all that apply.)
a. Hot flashes
b. Weight loss
d. Decrease in exercise capacity
e. Cold intolerance
ANS: C, D, E
Symptoms include weight gain, lethargy, decrease in exercise capacity, and intolerance to cold. Other presentations might include constipation, hoarseness, hair loss, and dry skin. Thyroid supplements are used to treat hyperthyroidism in pregnancy.
3. Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. What do these complications include? (Select all that apply.)
c. Intrauterine fetal death (IUFD)
f. Autonomic neuropathy
ANS: A, B, D, E
These structural changes will most likely affect a variety of systems, including the heart, eyes, kidneys, and nerves. IUFD (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.
1. Achieving and maintaining euglycemia are the primary goals of medical therapy for the pregnant woman with diabetes. These goals are achieved through a combination of diet, insulin, exercise, and blood glucose monitoring. The target blood glucose levels 1 hour after a meal should be _____________.
110 to 129 mg/dl
Target levels of blood glucose during pregnancy are lower than nonpregnant values. Accepted fasting levels are between 60 and 99 mg/dl, and 1-hour postmeal levels should be between 110 to 129 mg/dl. Two-hour postmeal levels should be 120 mg/dl or less.
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.
Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Although advanced maternal age may pose some health risks, the most important factor for the woman with pregestational diabetes remains the degree of glycemic control during pregnancy. The number of years since diagnosis and the amount of insulin required are not as relevant to outcomes as the degree of glycemic control.
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 greater risk.
Congenital malformations account for 30% to 50% of perinatal deaths in diabetic pregnancies. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome, and the transition to extrauterine life is often marked by hypoglycemia and other metabolic abnormalities.
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 four times a day and at bedtime.
d. Dietary management involves distributing nutrient requirements over three meals and two or three snacks.
Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis. 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.
Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control.
Which of the following findings is not likely to be seen in a pregnant patient who has hypothyroidism?
c. Gestational hypertension
d. Placental abruption
Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm; these outcomes can be improved with early diagnosis and treatment. Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism.
A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. The primary goal of her treatment at this time is to:
a. Rest the gastrointestinal (GI) tract by restricting all oral intake for 48 hours.
b. Reduce emotional distress by encouraging the woman to discuss her feelings.
c. Reverse fluid, electrolyte, and acid-base imbalances.
d. Restore the woman’s ability to take and retain oral fluid and foods.
Fluid, electrolyte, and acid-base imbalances present the greatest immediate danger to the well-being of the mother and fetus and should be corrected as soon as possible. Resting the GI tract and discussing her feelings are components of treatment but are not immediate goals for this client. The ability to retain oral fluid and foods is a longer-term goal of treatment for this condition.
A patient who is pregnant already has Type 2 diabetes with a hemoglobin A1c value of 7. The nurse would categorize this patient as having:
a. Gestational diabetes.
b. Insulin-dependent diabetes complicated by pregnancy.
c. Pregestational diabetes mellitus.
d. Non–insulin-dependent diabetes with complications.
Pregestational diabetes mellitus is a term used to describe patients with type 1 or type 2 diabetes in whom diabetes existed prior to pregnancy. Gestational diabetes occurs when a woman becomes diabetic during the pregnancy state. Type 2 diabetes is non–insulin-dependent. None of the information presented indicates complications at this point, because the hemoglobin A1c is within normal range, signifying adequate glycemic control.
The priority assessment in evaluating a pregnant woman with severe nausea and vomiting is:
a. Fasting blood glucose level.
d. White blood cell count.
Determination of ketonuria would be a critical assessment that would lead towards determination of hyperemesis. A pregnant patient with severe nausea and vomiting may have hyperemesis gravidarum and as such requires critical monitoring to determine the nature of the problem. An FBS measurement, although informative, would not be the priority assessment at this time, nor would a bilirubin measurement. A WBC count would indicate the possibility of an infectious source but it would not be a priority assessment in terms of the patient’s presentation.
A pregnant woman has maternal phenylketonuria (PKU) and is interested in whether or not she will be able to breastfeed her baby. Which reaction by the nurse indicates accurate information?
a. The patient can breastfeed the baby as long as she continues to maintain a PKU-restricted diet.
b. The patient should alternate breastfeeding with bottle feeding in order to reduce PKU levels provided to the baby.
c. The patient should be advised to not breastfeed the infant because her breast milk will contain large amounts of phenylalanine.
d. The patient can breastfeed for the first 3 months without any untoward effects on the infant.
Breastfeeding is not advised for a patient who has maternal PKU, because phenylalanine levels are high in such a patient’s breast milk. Dietary restriction will not limit the amount of this substance in breast milk. Alternating feeding sources is not advised either.
A nurse is working with a diabetic patient who recently found out she is pregnant. In coordinating an interdisciplinary team to help manage the patient throughout the pregnancy, the nurse would include: (Select all that apply.)
a. Family practice physician
d. Occupational therapist
f. Speech therapist
Ans: B, C, E
An internal medicine practitioner rather than family practice physician would be included on the interdisciplinary care team. A dietician would be included to help the patient with dietary planning, a perinatologist to take care of the maternal-fetal unit, and a nephrologist to monitor renal function. There is no need for an occupational therapist or a speech therapist unless other issues arise.