Endocrine and Metabolic Disorders in Pregnancy

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.

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 due to increased insulin production by the pancreas and increased peripheral sensitivity to insulin. Insulin resistance begins as early as 14 to 16 weeks of gestation and continues to rise until it stabilizes during the last few weeks of pregnancy. During the first trimester maternal blood glucose levels are reduced and the insulin response to glucose is enhanced; therefore, this is when an episode of hypoglycemia is most likely to occur. For the nonbreastfeeding mother insulin levels return to normal within 7 to 10 days. Lactation uses maternal glucose; therefore, the mother's insulin requirements remain low during lactation. On completion of weaning the mother's prepregnancy insulin requirement is reestablished.

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.

In teaching a woman with pregestational diabetes about desired glucose levels, the nurse explains that a normal fasting glucose level, such as before breakfast, is in the range of: a. 65 to 95 mg/dl b. 130 to 140 mg/dl c. <120 mg/dl d. 150 to 180 mg/dl

ANS: A Target glucose levels premeal or during a fasting period are 65 to 95 mg/dl. A glucose level of 130 to 140 mg/dl is consistent with expected levels 1 hour postmeal. A glucose level of <120 mg/dl is consistent with expected levels of glucose 2 hours postmeal. A glucose level of 150 to 180 mg/dl is considered elevated for a fasting glucose level and indicates poor glycemic control.

A serious but uncommon complication of undiagnosed or partially treated hyperthyroidism is thyroid storm, which may occur in response to stress such as infection, birth, or surgery. Symptoms of this emergency disorder include (choose all that apply): a. Fever b. Hypothermia c. Restlessness d. Bradycardia e. Hypertension

ANS: A, C Fever, restlessness, tachycardia, vomiting, hypotension, and stupor are symptoms of a thyroid storm. Fever, not hypothermia; tachycardia, not bradycardia; and hypotension, not hypertension, are symptoms of thyroid storm.

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 rather than her recent diagnosis of diabetes. A number of 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. 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 to have greater concern for changes to her social life than to adopting a new self-care regimen.

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.

A nurse caring for a woman hospitalized for hyperemesis gravidarum expects that initial treatment will involve: a. Corticosteroids to reduce inflammation b. IV therapy to correct fluid and electrolyte imbalances c. An antiemetic, 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 for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. 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. This is not the initial treatment for this client.

A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? a. Hyperthyroidism b. Phenylketonuria c. Hypothyroidism d. Thyroid storm

ANS: B Phenylketonuria (PKU) is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and should therefore elect not to breastfeed. A woman with hyperthyroidism would have no particular reason not to breastfeed. A woman with hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding.

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.

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 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.

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 receive insulin treatment until 6 weeks after birth d. Type 1 diabetes may become type 2 during pregnancy

ANS: B Type 2 often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2, 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 type 1 and type 2 diabetes.

During a prenatal visit a nurse is explaining dietary management to a woman with pregestational diabetes. The nurse evaluates that teaching has been effective when the woman states: 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 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

A nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: a. Is 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. Levels should remain at less than 7 d. Is done on the woman's urine, not her blood

ANS: C Hemoglobin Alc levels greater than 7 indicate elevated glucose during the previous 4 to 6 weeks. This is an extra test for diabetic women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood.

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should know 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 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.