Ch.11 Pregnancy at risk: Preexisting conditions(questions and answers)

1. 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." ANS: A Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. "Insulin dosage will likely need to be increased during the second and third trimesters," "Episodes of hypoglycemia are more likely to occur during the first 3 months," and "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding" are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy. 2. 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 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 because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia. 00:19 01:14 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. ANS: D Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. 4. Concerning the use and abuse of legal drugs or substances, nurses should be aware that: a.Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health. b.Caucasian women are more likely to experience alcohol-related problems. c.Coffee is a stimulant that can interrupt body functions and has been related to birth defects. d.Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed. ANS: B African-American and poor women are more likely to use illicit substances, particularly cocaine, whereas Caucasian and educated women are more likely to use alcohol. 5. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: 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 woman. 6. A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 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 ANS: 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. 7. 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. 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 uncertain etiology, or who have given birth to microcephalic infants. 8.. 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. ANS: B Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, 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. 9. Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand 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. 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 insulin 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. 10. 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. 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. 11. 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. ANS: 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. 12. 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. ANS: 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. 13. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which 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; it is 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. ANS: D 60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 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 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL. 14. A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? a.Hyperthyroidism b.Phenylketonuria (PKU) c.Hypothyroidism d.Thyroid storm ANS: 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 15. 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 about her recent diagnosis of diabetes. Several 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. 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 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 she may not participate in the plan of care until understanding takes place. 16. When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include: 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. ANS: 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. 17. 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. ANS: 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 after myocardial infarction. 18. 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. ANS: 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. 19. 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 ANS: 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. 20. The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this client population the nurse must be cognizant that methamphetamine: a.Is similar to opiates. b.Is a stimulant with vasoconstrictive characteristics. c.Should not be discontinued during pregnancy. d.Is associated with a low rate of relapse. ANS: B Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are used similarly. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high. 21. 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 b.1 in 1200 c.1 in 2500 d.1 in 3000 ANS: D Cystic fibrosis occurs in about 1 in 3000 Caucasian live births. 22. Which heart condition is not a contraindication for pregnancy? a.Peripartum cardiomyopathy b.Eisenmenger syndrome c.Heart transplant d.All of these contraindicate pregnancy. ANS: 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.