Chapter 26: Concurrent Disorders during Pregnancy McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition

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.

ANS: B congenital anomalies in the fetus.

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.

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 patient 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."

ANS: A "I will need to increase my insulin dosage during the first 3 months of pregnancy."

Insulin needs are reduced in the first trimester due to increased insulin production by the pancreas and increased peripheral sensitivity to insulin. Also the woman may be experiencing nausea, vomiting, and anorexia that would decrease her insulin needs. The other statements show good understanding of this topic.

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.

ANS: A macrosomia.

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.

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. there is only one type of gestational diabetes.

d. type 1 diabetes may become type 2 during pregnancy.

ANS: B type 2 diabetes often goes undiagnosed.

Type 2 often goes undiagnosed, because hyperglycemia develops gradually and often is not severe. Type 2, previously called adult onset diabetes, is the most common. There are 2 subgroups of gestational diabetes. Type GDM A1 is diet-controlled whereas type GDM A2 is controlled by insulin and diet. People do not go back and forth between type 1 and type 2 diabetes.

A nurse in labor and delivery learns about metabolic changes that occur throughout pregnancy in diabetes. What information does the nurse 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.

ANS: C During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.

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. Maternal insulin requirements may double or quadruple by the end of pregnancy.

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 Hypoglycemia

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, 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, releasing large amounts of bilirubin into the neonate's circulation, which results in hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia.

Which factor is known to increase the risk of gestational diabetes mellitus?

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: D Previous diagnosis of type 2 diabetes mellitus

Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already is a diabetic and will continue to be so during and after pregnancy.

Glucose metabolism is profoundly affected during pregnancy because

a. pancreatic function in the islets of Langerhans is affected by pregnancy.

b. the pregnant woman uses glucose at a more rapid rate than the nonpregnant woman.

c. the pregnant woman increases her dietary intake significantly.

d. placental hormones are antagonistic to insulin, resulting in insulin resistance.

ANS: D placental hormones are antagonistic to insulin, resulting in insulin resistance.

Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is 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.

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by doing which of the following?

a. Eating six small equal meals per day

b. Reducing carbohydrates in her diet

c. Eating her meals and snacks on a fixed schedule

d. Increasing her consumption of protein

ANS: C Eating her meals and snacks on a fixed schedule

Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake or increased protein intake. Approximately 45% of the food eaten should be in the form of carbohydrates.

A pregnant diabetic woman is in the hospital and her blood glucose reading is 42 mg/dL. What action by the nurse is best?

a. Provide her with 15 grams of oral carbohydrate if she can swallow.

b. Administer a bolus of rapid-acting insulin.

c. Order the woman a meal tray from the cafeteria.

d. Notify the provider immediately.

ANS: A Provide her with 15 grams of oral carbohydrate if she can swallow.

This woman has hypoglycemia and needs to injest 15 grams of carbohydrate if she is able to swallow. Insulin would make the problem worse. The meal tray is a good idea but not as the first response as it will take too long. The provider should be notified but only after the nurse takes corrective action.

Nursing intervention for the pregnant diabetic is based on the knowledge that the need for insulin

a. increases throughout pregnancy and the postpartum period.

b. decreases throughout pregnancy and the postpartum period.

c. varies depending on the stage of gestation.

d. should not change because the fetus produces its own insulin.

ANS: C varies depending on the stage of gestation.

Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells.

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 rarely occurs in diabetic pregnancies.

c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies.

d. Women should not use insulin pumps during pregnancy.

ANS: A Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy

Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios is a potential complication for the diabetic pregnancy. Infections are more common and more serious in pregnant women with diabetes. Women who were treated with an insulin pump before pregnancy can continue this therapy.

What form of heart disease in women of childbearing years usually has a benign effect on pregnancy?

a. Cardiomyopathy

b. Rheumatic heart disease

c. Congenital heart disease

d. Mitral valve prolapse

ANS: D Mitral valve prolapse

Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension or endocarditis during pregnancy.

When teaching the pregnant woman with class II heart disease, what information should the nurse provide?

a. Advise her to gain at least 30 lb.

b. Explain the importance of a diet high in calcium.

c. Instruct her to avoid strenuous activity.

d. Inform her of the need to limit fluid intake.

ANS: C Instruct her to avoid strenuous activity.

Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight gain should be kept at a minimum with heart disease. Iron and folic acid intake is important to prevent anemia. Fluid intake should not be limited during pregnancy. She may also be put on a diuretic. Fluid intake is necessary to prevent fluid deficits.

Prophylaxis of subacute bacterial endocarditis (SBE) is given before and after birth when a pregnant woman has

a. valvular disease.

b. congestive heart disease.

c. dysrhythmias.

d. postmyocardial infarction.

ANS: A valvular disease.

Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve prolapse. It is not indicated for congestive heart failure, dysrhythmias, or myocardial infarctions.

The nurse understands that postpartum care of the woman with cardiac disease

a. is the same as that for any pregnant woman.

b. includes rest 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.

ANS: B includes rest and monitoring of the effect of activity.

After delivery, the woman with cardiac disease should rest, and the nurse monitors her for the effect activity has on her cardiovascular status. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

In caring for a pregnant woman with sickle cell anemia the nurse is aware that signs and symptoms of sickle cell crisis include

a. anemia.

b. endometritis.

c. fever and pain.

d. urinary tract infection.

ANS: C fever and pain.

Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Signs of crisis do not include anemia, endometriosis, or UTI.

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.

ANS: A it is the most common medical disorder of pregnancy.

Iron deficiency anemia causes 75% of anemias in pregnancy. It is difficult to meet the pregnancy needs for iron through diet alone. It does not cause bradycardia. Thalassemia is a distinct disease from sickle cell anemia.

For which of the infectious diseases can a woman be immunized?

a. Toxoplasmosis

b. Rubella

c. Cytomegalovirus

d. Herpesvirus type 2

ANS: B Rubella

Rubella is the only infectious disease listed for which a vaccine is available.

A woman who delivered her third child yesterday has just learned that her two school-age children have contracted chickenpox. What action by the nurse is best?

a. Assess if the woman has had chickenpox or been vaccinated.

b. Tell her that the baby has immunity from her and is not susceptible.

c. Advise her if she is non-immune, she will get vaccinated at her 2-week postpartum checkup.

d. The infant will receive prophylactic acyclovir before discharge.

ANS: A Assess if the woman has had chickenpox or been vaccinated.

The first thing the nurse should do is to determine the woman's susceptibility to this infection. If she is non-immune, she will get her first vaccination prior to discharge. The nurse does not know the baby's immune status without knowing the mother's. Acyclovir is not used to treat chickenpox.

A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?

a. Provide a low-protein diet.

b. Offer the vaccine.

c. Discuss the recommendation to bottle-feed her baby.

d. Practice respiratory isolation.

ANS: B Offer the vaccine.

A person who has a history of high-risk behaviors should be offered the hepatitis B vaccine. A low-protein diet will not prevent the infection. The first trimester is too early to discuss feeding methods. Respiratory isolation is not needed for this blood- and body fluid-borne disease.

A woman has tested human immunodeficiency virus (HIV)-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?

a. "Even though my test is positive, my baby might not be affected."

b. "I know I will need to have an abortion as soon as possible."

c. "This pregnancy will probably decrease the chance that I will develop AIDS."

d. "My baby is certain to have AIDS and die within the first year of life."

ANS: A "Even though my test is positive, my baby might not be affected."

The rate of perinatal transmission of HIV has decreased with the use of antiretroviral medications during pregnancy. There is no need to have an abortion. The mother may or may not go on to develop AIDS.

A nurse has taught a pregnant woman about toxoplasmosis. What statement by the patients indicates a need for further instruction?

a. "I will be certain to empty the litter boxes regularly."

b. "I won't eat raw eggs."

c. "I had better wash all of my fruits and vegetables."

d. "I need to be cautious when cooking meat."

ANS: A "I will be certain to empty the litter boxes regularly."

The patient should avoid contact with materials that are possibly contaminated with cat feces while pregnant. This includes cat litter boxes, sand boxes, and garden soil. She should wash her hands thoroughly after working with soil or handling animals. The other statements show good understanding.

A woman who had no prenatal care has just delivered after a brief labor. The baby has rough, dry skin; is large for gestational age; and has an umbilical hernia. What action by the nurse is most appropriate?

a. Question the mother about substance abuse.

b. Reassess the baby's gestational age.

c. Inform the mother her thyroid levels will be checked.

d. Perform a bedside blood glucose test on the mother.

ANS: C Inform the mother her thyroid levels will be checked.

These signs in the newborn are indicative of hypothyroidism. The mother will have thyroid levels checked. Asking about substance abuse, reassessing gestational age, and obtaining a blood glucose reading are all unnecessary.

A woman in the perinatal clinic asks the nurse how her asthma will affect her pregnancy and fetus. What response by the nurse is best?

a. Asthma medications cannot be used during pregnancy.

b. The only problem is that you will not be able to breastfeed.

c. Medications for asthma do not appear to harm the fetus.

d. Pregnancy tends to make asthma worse.

ANS: C Medications for asthma do not appear to harm the fetus.

Medications for asthma seem to be well tolerated during pregnancy. Breastfeeding is safe for the newborn. The course of asthma is variable in pregnancy.

A woman has been admitted to the labor and delivery unit who is HIV positive. She is in active labor. What action by the nurse is most appropriate?

a. Prepare to administer IV zidovudine.

b. Place the mother on contact precautions.

c. Administer oxygen by face mask.

d. Notify social services.

ANS: A Prepare to administer IV zidovudine.

During labor, an IV infusion of zidovudine is administered. The woman does not need contact precautions; standard precautions suffice. The woman does not need oxygen because of her HIV status. There is no reason to notify social services.

The student nurse learns that maternal complications of diabetes include which of the following? (Select all that apply.)

a. Atherosclerosis

b. Retinopathy

c. IUFD

d. Nephropathy

e. Caudal regression syndrome

ANS: A, B, D

Maternal complications of diabetes include heart disease, retinopathy, nephropathy, and neuropathy. Stillbirth and caudal regression syndrome are fetal complications.

Congenital anomalies can occur with the use of antiepileptic drugs, including (Select all that apply.)

a. Craniofacial abnormalities

b. Congenital heart disease

c. Neural tube defects

d. Gastroschisis

e. Diaphragmatic hernia

ANS: A, B, C

Congenital anomalies that can occur with antiepileptic drugs include craniofacial abnormalities, congenital heart disease, and neural tube defects. They are not known to cause gastroschisis or diaphragmatic hernias.

The student nurse learns that maternal risks of systemic lupus erythematosus include (Select all that apply.)

a. Premature rupture of membranes (PROM)

b. Fetal death resulting in stillbirth

c. Hypertension

d. Preeclampsia

e. Renal complications

ANS: A, C, D, E

PROM, hypertension, preeclampsia, and renal complications are all maternal risks associated with SLE. Stillbirth and prematurity are fetal risks of SLE.

When caring for a pregnant woman with suspected cardiomyopathy, the nurse must be alert for signs and symptoms of cardiac decompensation, which include (Select all that apply.)

a. A regular heart rate

b. Hypertension

c. Shortness of breath

d. Weakness

e. Crackles in the lung bases

ANS: C, D, E

Some symptoms of cardiomyopathy include shortness of breath, weakness, and crackles in the lung bases. A regular heart rate may or may not be present. Hypertension is not a typical finding.