Chapter 29 Flashcards
- 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
c. Hydramnios
d. Hyperemesis gravidarum
ANS: B
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.
- 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.”
ANS: C
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.
- 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?
a. Macrosomia
b. Congenital anomalies of the central nervous system
c. Preterm birth
d. Low birth weight
ANS: 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 fetus.
- 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
ANS: B
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.”
- 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.
ANS: 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 an uncertain cause, or who have given birth to microcephalic infants.
- 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
ANS: B
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.
- 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.
ANS: B
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.
- 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.
ANS: 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 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.
- 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.
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.
- 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.
ANS: C
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.
- A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding?
a. Hyperthyroidism
b. PKU
c. Hypothyroidism
d. Thyroid storm
ANS: B
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.
- 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
ANS: 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 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.
- 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.
ANS: D
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.
- Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
a. Hypoglycemia
b. Hypercalcemia
c. Hypobilirubinemia
d. Hypoinsulinemia
ANS: A
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.
- 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
ANS: C
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.
