306 Ricci Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

6% The upper normal level of HbA1C is 6% of total hemoglobin.

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which statement by the client reveals an understanding about the preexisting condition?

"I understand that my fetus and I are both at risk for complications" When a woman enters pregnancy with a preexisting condition, both she and her fetus can be at risk of developing complications.

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

decrease activity and rest more often If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend an increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource?

formula It is possible to transmit HIV via breastfeeding, and formula is the only option for feeding. The nurse needs to provide positive information and offer to make a referral or get assistance for clients who may be in financial need. In this case, acquiring adequate amounts of formula would be the priority. The diapers and a car seat are also necessary but would follow the formula. The client would not need a breast pump since she cannot give the milk to her baby.

Which should the nurse identify as a risk associated with anemia during pregnancy?

preterm birth The nurse should identify preterm birth as a risk associated with anemia during pregnancy. Anemia during pregnancy does not increase the risk of a newborn with heart problems, an enlarged liver, or fetal asphyxia.

A nurse is caring for a newborn with fetal alcohol spectrum disorder. What characteristic of the fetal alcohol spectrum disorder should the nurse assess for in the newborn?

small head circumference The nurse should assess for small head circumference in a newborn being assessed for fetal alcohol spectrum disorder. Fetal alcohol spectrum disorder does not cause decreased blood glucose level, a poor breathing pattern, or wide eyes.

The nurse is assessing a pregnant client who has a long history of asthma. She states, "I'm trying not to use my asthma medications because I certainly don't want my baby exposed to them." What is the nurse's best response?

"Actually, having uncontrolled asthma is much riskier for you and the baby than the medication" It is important for pregnant clients with asthma to keep taking their medications because the risks of exacerbations exceed the risks of the medications.

A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition?

cytomegalovirus The nurse would be alert for the development of cytomegalovirus infection. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in day care centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breastfeeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.

The nurse is assessing a woman with class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure?

persistent rales in the bases of the lungs The earliest warning sign of cardiac decompensation is persistent rales in the bases of the lungs.

The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy?

pulmonary hypertension Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.

The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or at delivery for her baby. Which statement by the mother indicates that further teaching is needed by the nurse?

"If my blood sugar is elevated, my baby's lungs will mature faster, which is good" Elevated blood sugars delay the maturation of fetal lungs, not increase maturation time, resulting in potential respiratory distress in newborns born to diabetic mothers. Doing "kick counts", as the fetal movement monitoring is often called, is standard practice, as is the possibility of an amniocentesis to determine lung maturity during the third trimester. Health care personnel should also prepare the mother for the potential of a cesarean section delivery if the infant is too large.

A woman in her 20s has a long history of sickle cell anemia and is 18 weeks' pregnant. What precautions would the nurse recommend the woman take to minimize the chance of experiencing a sickle cell crisis?

get at least 8 hours sleep each night A pregnant woman with sickle cell anemia needs to *get adequate rest, drink fluids to maintain hydration, avoid extreme cold situations, go bi-weekly for doctor visits during the second trimester for closer monitoring, and eat a well-balanced diet*. Jaundice may be noted due to the breakdown of RBCs and does not necessitate immediate notification of the physician.

At 24 weeks' gestation, a client's 1-hour glucose tolerance test is elevated. The nurse explains that, based on this finding, the client will need to take which action?

3-hour glucose tolerance test for follow up The 1-hour glucose tolerance test is a screening procedure. If the results are elevated, the client needs a 3-hour glucose tolerance test, which is diagnostic of gestational diabetes. Since this is only a screening test, no treatment for gestational diabetes, such as finger-sticks or insulin, is implemented until the 3-hour glucose tolerance test result determines if the client has gestational diabetes. An HgbA1C level does not rule out diabetes; it monitors average blood glucose level over an extended period of time.

The clinic nurse teaches a pregestational type 1 diabetic client that constant insulin levels are very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

an insulin pump Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully she maintains her diet and balances her exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.

The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize?

check blood sugar levels daily An elevated blood glucose is concerning for diabetes. A fasting blood glucose level of greater than 140 mg/dl (7.77 mmol/L) or random level of greater than 200 mg/dl (11.10 mmol/L) is concerning; this must be followed up to ensure the client is not developing gestational diabetes. The hemoglobin and hematocrit are within normal limits for this client. The values should be hemoglobin greater than 11 g/dl (110 g/L) and hematocrit greater than 33% (0.33). Values lower than that are possible indications of anemia and would necessitate further evaluation. An individual with higher than normal blood glucose levels is at risk for developing urinary tract infection. This will usually happen after the glucose levels are elevated. Anemia can be treated by increasing the consumption of iron-enriched foods and taking a daily iron supplement.

A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?

exercise The three main facets to glycemic control for the woman with pregestational diabetes are diet, exercise, and insulin. An individual with type 1 diabetes uses insulin and not oral hypoglycemic agents. Vitamin supplements may assist with helping to keep the woman healthy but not necessarily through glycemic control. It will be important for the woman to get enough rest throughout the pregnancy but this will not assist with glycemic control.

A nurse is conducting a presentation about prenatal care and preexisting maternal conditions. When discussing the various risks to the mother and infant, the nurse would include information about which condition as the leading cause of intellectual disability in the United States?

fetal alcohol spectrum disorder Fetal alcohol spectrum disorder is a lifelong yet completely preventable set of physical, mental, and neurobehavioral birth defects. It is the leading cause of intellectual disability in the United States.

What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension?

stressing the positive benefits of a healthy lifestyle The nurse should stress the positive benefits of a healthy lifestyle during the preconception counseling of a client with chronic hypertension. The client need not avoid dairy products or increase intake of vitamin D supplements. It may not be advisable for a client with chronic hypertension to exercise without consultation.

A pregnant client has tested positive for hepatitis B virus. When discussing the situation with the client, the nurse explains that her newborn will be vaccinated with an initial HBV vaccine dose at which time?

within 12 hours of birth If a woman tests positive for HBV, the newborn will receive HBV vaccine within 12 hours of birth. The second dose will be given at 1 month and the third dose at 6 months.

A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion?

1500 For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain this level. The insulin infusion would be given at 1500, based on the blood glucose level being higher than 110 mg/dL (6.11 mmol/L).

A nurse is conducting a class for a group of pregnant women about ways to minimize the risk of infection during pregnancy. One of the infections that the nurse is discussing is toxoplasmosis. The nurse determines that the class was successful when the group identifies which action(s) as helpful in preventing this infection. Select all that apply.

"Any cutting surface used for raw meats should be washed afterwards with hot, soapy water." "Peeling any raw vegetables is a good idea before eating them." "It is important to wear gardening gloves when digging in the soil." Pregnant women should do the following to prevent toxoplasmosis: avoid eating raw or undercooked meat, especially lamb or pork. Cook all meat to an internal temperature of 160°F (71°C) throughout; clean cutting boards, work surfaces, and utensils with hot, soapy water after contact with raw meat or unwashed fruits and vegetables. Peel or thoroughly wash all raw fruits and vegetables before eating them; keep the cat indoors to prevent it from hunting and eating birds or rodents; and wear gardening gloves when in contact with outdoor soil.

A pregnant client is diagnosed with syphilis. Which response would demonstrate respect for the client and therapeutic communication?

"I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." The nurse needs to be supportive, empathic and accepting of the client, asking open-ended questions and acting calm and reassuring to her. By acknowledging her fears for her fetus, the nurse is demonstrating respect for her and conveying confidence that the client is trying to take care of her fetus.

A mother is talking to the nurse and is concerned about managing her asthma while she is pregnant. Which response to the nurse's teaching indicates that the woman needs further instruction?

"I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring." A pregnant woman with a history of asthma needs to be proactive, taking her inhalers and other asthma medications to prevent an acute asthma attack. She needs to understand that it is far more dangerous to not take the medications and have an asthma attack. She also needs to monitor her peak flow for decreases, be aware of triggers, and avoid them if possible. However, a pregnant woman should never begin allergy shots if she has not been taking them previously, due to the potential of an adverse reaction.

A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement?

"I will take the iron with milk instead of orange or grapefruit juice" The pregnant client should take the iron supplement with vitamin C-containing fluids such as orange juice, which will promote absorption, rather than milk, which can inhibit iron absorption. Taking iron on an empty stomach improves its absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman is advised to take it with meals. The woman also needs instruction about adverse effects, which are predominantly gastrointestinal and include gastric discomfort, nausea, vomiting, anorexia, diarrhea, metallic taste, and constipation. Taking the iron supplement with meals and increasing intake of fiber and fluids helps overcome the most common side effects. If the woman misses a dose, she should take a dose as soon as she remembers.

A young adult woman comes to the clinic for a routine check-up. During the visit, the woman who works in a day care facility tells the nurse that she and her partner are considering having a baby. "We are concerned that I might be exposed to common childhood illnesses." The woman undergoes testing and finds out that she is not immune from chickenpox. Based on this information, which information would the nurse give to the client?

"You will need to get vaccinated now and wait at least 1 months before getting pregnant" Preconception counseling is important for preventing chickenpox (varicella). A major component of counseling involves determining the woman's varicella immunity. Vaccination is the cornerstone of prevention. The vaccine is administered if needed. Varicella vaccine is a live attenuated viral vaccine. It should be administered to all adolescents and adults 13 years of age and older who do not have evidence of varicella immunity. Therefore, the woman should be vaccinated now before she becomes pregnant and then wait at least 1 month before getting pregnant. The varicella vaccine is contraindicated for pregnant women because the effects of the vaccine on the fetus are unknown. There is no need for the woman to quit her job once she is immunized nor does she need to take a leave of absence during the winter and spring months when the incidence is highest. Chickenpox does occur and is highly contagious. Maternal varicella can be transmitted to the fetus through the placenta, leading to congenital varicella syndrome if the mother is infected during the first half of pregnancy via an ascending aorta.

A pregnant woman is diagnosed with hyperthyroidism and is prescribed propylthiouracil as part of the treatment plan. When teaching the woman about this medication and its effect on the fetus, which information would the nurse include?

"Your baby might be born with an enlarged thyroid gland" Treatment for hyperthyroidism is with thioamides (methimazole or propylthiouracil), which reduce thyroid activity. These drugs, unfortunately, cross the placenta and can lead to congenital hypothyroidism and, consequently, an enlarged thyroid gland (i.e., a goiter) in the fetus. Women should be regulated on the lowest possible dose of the drug and cautioned to keep a careful record of doses taken so they do not forget or unintentionally duplicate a dose; doing so could be dangerous, because if a goiter in the fetus enlarges enough, it can obstruct the airway and make resuscitation difficult at birth. The drug does not increase the risk for diabetes or blood clotting problems.

A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?

"your primary care provider will order safe doses of your medication" Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.

A woman comes to the clinic for her first prenatal visit. As part of the assessment, the woman is screened for rubella antibodies. The nurse determines that a client has immunity against rubella based on which rubella titer?

1:8 A rubella antibody titer of 1:8 or greater proves evidence of immunity. Women with titers of less than 1:8 should be immunized.

A pregnant woman with diabetes is having her hemoglobin (glycosylated) level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result?

6.5% A hemoglobin (glycosylated) level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level less than 7% indicates that the plan is working and should be continued.

A pregnant woman with diabetes is having a glycosylated hemoglobin (HgbA1C) level drawn. Which result would require the nurse to revise the client's plan of care?

8.5% A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. Therefore, the nurse would need to revise the plan of care.

A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?

Both parents have to carry the trait Sickle cell anemia is an autosomal recessive disease requiring that the person have two genes for the disease, one from each parent. If one parent has the disease and the other is free of the disease and trait, the chances of the child inheriting the disease is zero. The infant will not develop the disease just because the mother has a crisis during the pregnancy.

After conducting a refresher class on possible congenital infections with a group of perinatal nurses, the nurse recognizes the class was successful when the group identifies which congenital viral infection as the most common?

CMV After conducting a refresher class on possible congenital infections with a group of perinatal nurses, the nurse recognizes the class was successful when the group identifies which congenital viral infection as the most common?

The nurse is doing meal planning with a pregnant woman with iron-deficiency anemia. What dietary recommendations would the nurse make to enhance the woman's intake of iron? Select all that apply.

Drink orange juice with the iron supplement. Increase intake of dried beans and green leafy vegetables. Cook food in an iron skillet, if possible. Dried fruits, fortified grains and cereals, and animal protein are all good sources of iron for a pregnant woman. Cooking in an iron skillet also will increase the amount of iron ingested. Vitamin C, like what is found in orange juice, enhances absorption of iron and is recommended to drink when taking iron supplements. Folate also increases the effectiveness of iron supplements; foods high in folate include green leafy vegetables, fortified grains and dried beans.

The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply.

Increased risk of spontaneous abortion Polyhydramnios Hypertension Women with pregestational diabetes, which is type 1 diabetes, are at a higher risk of having an infant with complications during the pregnancy and at the birth. Spontaneous abortion is higher in women who have pregestational diabetes. Also, they run a higher risk of having a pregnancy with polyhydramnios, and of developing maternal hypertension. The birth weight of an infant born to a mother with diabetes is increased, not decreased. Cystic fibrosis is not associated with maternal diabetes.

A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?

acknowledge her need to leave but ask her to demonstrate the use of an inhaler and peak flow meter before she goes; remind her to take her regular medications Management of asthma during pregnancy is very important; the nurse must document that the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication and to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications. Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of his/her obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result?

an induration wheal over 10mm in diameter appears in 48 to 72 hours A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat, circumscribed area.

A nurse is caring for a pregnant client. The initial interview reveals that the client is accustomed to drinking coffee at regular intervals. For which increased risk should the nurse make the client aware?

anemia The nurse should make the client aware of increased risk of anemia as a possible effect of maternal coffee consumption during pregnancy, as it decreases iron absorption. Maternal coffee consumption during pregnancy does not increase the risk of heart disease, rickets, or scurvy.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?

assessing for cardiac decompensation The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.

What important instruction should the nurse give a pregnant client with tuberculosis?

maintain adequate hydration The nurse should instruct the pregnant client with tuberculosis to maintain adequate hydration as a health-promoting activity. The client need not avoid direct sunlight or red meat, or wear light clothes; these have no impact on the client's condition.

A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority?

avoidance of infection Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.

A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?

chorionic villus sampling Chorionic villus sampling is the earliest method (8 to 10 weeks gestation) to test the fetal genetics for anomalies. This testing might be offered if the mother wants specific information on the genetics of the fetus as early as possible in pregnancy. Amniocentesis is generally done between 14 and 18 weeks' gestation, but can be done as early as 10 weeks' gestation. Maternal serum alpha-fetoprotein are usually done at 16 to 20 weeks' gestation, and triple screening is performed between 15 and 20 weeks' gestation.

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?

dyspnea, crackles, and irregular weak pulse The nurse should be alert for signs of cardiac decompensation due to congestive heart failure, which include crackles in the lungs from fluid, difficulty breathing, and weak pulse from heart exhaustion. The heart rate would not be regular, and a cough would not be dry. The heart rate would increase rather than decrease.

The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition?

gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

A nurse is obtaining a medication history from a pregnant client with a history of systemic lupus erythematosus (SLE). Which medication(s) would the nurse expect the woman to report to be currently using? Select all that apply.

hydroxychloroquine ibuprofen prednisone Treatment of SLE in pregnancy is generally limited to NSAIDs like ibuprofen, prednisone, and an antimalarial agent, hydroxychloroquine. Methotrexate and leflunomide are used to treat rheumatoid arthritis but are contraindicated for use in pregnancy because of the potential for fetal toxicity.

Which changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation?

hypercoagulable state The nurse should identify that the increased risk of arterial thrombosis in atrial fibrillation is due to the hypercoagulable state of pregnancy. During pregnancy, there is a state of hypercoagulation. This increases the risk of arterial thrombosis in clients having atrial fibrillation and artificial valves. Increased cardiac output and blood volume do not cause arterial thrombosis. Elevation of the diaphragm is due to the uterine distension, and it causes a shift in the QRS axis and is not associated with arterial thrombosis.

Cytomegalovirus infection can result in different congenital anomalies. It can also be transmitted via different routes. When discussing this infection with a pregnant woman, the nurse integrates understanding that permanent fetal disability can occur with which type of transmission of CMV?

in utero transmission There are three time periods during which mother-to-child transmission can occur; however, permanent disability occurs only in association with in utero infection. Such disability can result from maternal infection during any point in the pregnancy, but more severe disabilities are usually associated with maternal infection during the first trimester.

An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?

increased risk of developing type 2 diabetes A mother who had gestational diabetes is at a 30% to 50% higher risk of developing type 2 diabetes mellitus than the general population. Long-term hypertension and heart disease are not associated with gestational diabetes, nor is weight gain following pregnancy. There is no data that validates long-term weight gain as a complication of gestational diabetes.

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client?

knowledge of child development The nurse should address the client's knowledge of child development during assessment of the pregnant adolescent client. The nurse need not address the sexual development of the client or whether sex was consensual. This would not be an opportune time to discuss birth control methods to be used after the pregnancy.

Which change in insulin is most likely to occur in a woman during pregnancy?

less effective than normal Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?

lie in a semi-recumbent position Semi-recumbent position is the best position for circulation of the mother and fetus. Lying flat on the back can induce supine hypotensive syndrome and fully recumbent impedes other circulation. The high Fowler position would not be comfortable for sleeping, as well as possibly impede the blood flow through the hips and lower abdomen.

The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?

maintain a daily blood glucose log Control of the blood glucose throughout the pregnancy is the primary goal to help decrease potential complications to both the mother and fetus. The mother should keep a daily log of her blood glucose levels and bring this log to each visit for the nurse to evaluate. The other choices of reporting possible signs of a UTI and working with a dietitian to plan menus would also be important but would be secondary to the blood glucose control. It would be inappropriate to discuss long-term goals at this time. This would be handled at a later time and would depend on the mother's situation.

A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn?

microcephaly Signs that are likely to be present in the 10% of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.

A pregnant woman diagnosed with diabetes should be instructed to perform which action?

notify the primary care provider if unable to eat because of nausea and vomiting During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

A pregnant client has developed iron-deficiency anemia and has been prescribed 200 mg of elemental iron per day. The nurse should encourage the client to take this medication with which substance?

orange juice Iron is absorbed best from an acid medium. Advise women, therefore, to take iron supplements with orange juice or a vitamin C supplement, which supplies ascorbic acid.

A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes? Select all that apply.

obesity hypertension previous large-for-gestational-age (LGA) infant Obesity, hypertension, and a previous infant weighing more than 9 lb (4 kg) are risk factors for developing gestational diabetes. Maternal age less than 18 years and genitourinary tract abnormalities do not increase the risk of developing gestational diabetes.

A nurse caring for a pregnant client suspects substance use during pregnancy. What is the priority nursing intervention for this client?

obtain a urine specimen for a drug screening Substance use during pregnancy is associated with preterm labor, spontaneous abortion (miscarriage), low birth weight, central nervous system and fetal anomalies, and long-term childhood developmental consequences. It is most important to know what the client is taking in order to provide the best care for the client and newborn.

A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which measure would the nurse stress with her during the remainder of the pregnancy?

obtaining enough rest As the blood volume doubles during pregnancy, heart failure can occur. The pregnant woman needs to obtain adequate rest to prevent overworking the heart. Fluid may need to be restricted.

The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement?

orange juice Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron. Dried fruit (such as apples), fortified grains, and dried beans are additional food choices that are rich in iron and should be included in her daily diet.

The nurse is caring for a 2-day-old newborn whose mother was diagnosed with cytomegalovirus during the first trimester. On which health care provider prescription should the nurse place the priority?

perform a hearing screen test Symptoms of CMV in the fetus and newborn, known as CMV inclusion disease, include *hepatomegaly, thrombocytopenia, IUGR, jaundice, microcephaly, hearing loss, chorioretinitis, and intellectual disability*. A hearing screen would be priority over monitoring growth and development because that will have to be done over an extended period of time. Urine and pulse are not important with this diagnosis.

A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?

placental abnormalities A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications.

A client in her first trimester comes to the clinic for an evaluation. Assessment reveals reports of fatigue, anorexia, and frequent upper respiratory infections. The client's skin is pale and the client is slightly tachycardic. The client also reports drinking about 6 cups of coffee on average each day. A diagnosis of iron-deficiency anemia is suspected. The client is scheduled for laboratory testing and the results are as follows: Hemoglobin 11.5 g/dL (115 g/L) Hematocrit 35% (0.35) Serum iron 32 µg/dL (5.73 µmol/L) Serum ferritin 90 ng/dL (90 µg/L) Which laboratory finding would the nurse correlate with the suspected diagnosis?

serum ferritin levels Laboratory tests for iron-deficiency anemia usually reveal *low hemoglobin (less than 11 g/dL or 110 g/L)*, *low hematocrit (less than 35% or 0.35)*, *low serum iron (less than 30 µg/dL or 5.37 µmol/L)*, microcytic and hypochromic cells, and *low serum ferritin (less than 100 ng/dL or 100 µg/L)*. The client's hemoglobin, hematocrit, and serum iron levels are borderline low normal, but the client's serum ferritin is below 100 ng/dL (100 µg/L), helping to support the diagnosis.

Over the past 20 weeks, the following blood pressure readings are documented for a pregnant client with chronic hypertension: week 16 - 130/86 mm Hg; week 20 - 138/88 mm Hg; week 24 - 136/82 mm Hg; and week 28 - 138/88 mm Hg. The nurse interprets these findings as indicating which classification of her blood pressure?

stage I Chronic hypertension exists when the woman has high blood pressure before pregnancy or before the 20th week of gestation, or when hypertension persists for more than 12 weeks. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Joint National Committee [JNC 8], 2018) blood pressure guidelines classify hypertension as follows: elevated: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg; Stage 1: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg; Stage 2: Systolic at least 140 mm Hg or diastolic at least 90 mm Hg; Hypertensive crisis: Systolic over 180 mm Hg and/or diastolic over 120 mm Hg (Alexander, 2019; Bakris, 2019). The client has stage 1 hypertension.

A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?

the viral load A woman who has HIV during pregnancy is at risk for transmitting the infection to the fetus during pregnancy or childbirth and to the newborn while breastfeeding. The type of birth, vaginal or cesarean, depends on several factors, including the woman's viral load, use of ART during pregnancy (not waiting until the birth), length of time membranes have been ruptured, and gestational age (not mother's age). With prenatal ART and prophylactic treatment of the newborn, there is a reduced risk of perinatal HIV transmission. The amniocentesis results would not be a factor in preventing the spread of HIV to the infant and may actually lead to the fetus being infected through the puncture site and bleeding into the amniotic sac.