OB _ Practice HESI Exam _ Gestational Diabetes _ Case Study _ 2023

1.The clinic nurse reviews Danielle's prenatal record prior to performing a nursing assessment. Danielle has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. How should the nurse record Danielle's obstetrical history using the G-T-P-A-L designation? a) 3-2-0-1-3 b) 4-1-1-1-2 c) 5-2-1-1-4 d) 4-2-1-0-2

GTPAL is 5-2-1-1-4 Danielle's GTPAL is 5-2-1-1-4 5 (pregnancies counting current one)- 2 (infants born at 38 and 41 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 10 weeks) - 4 (each twin and the 2 singletons, all living).

Which response should the nurse give to the client? (Select all that apply. One, some, or all options may be correct.) a) "Hyperglycemia often presents as increased thirst and urination." b) "Hyperglycemia causes a headache and flushed, dry skin." c) "Hyperglycemia causes cool and clammy skin." d) "Hyperglycemia causes an increased sensation of being hungry."

a) "Hyperglycemia often presents as increased thirst and urination." b) "Hyperglycemia causes a headache and flushed, dry skin." A. This is accurate. Hyperglycemia manifestations include increased thirst and increased urination. B. This is accurate. Hyperglycemia symptoms include headache and flushed, dry skin.

Mother-Baby Care Labor and delivery transfers the clients, and their care is assumed by the mother-baby nurses without incident. The labor and delivery nurse reports to the postpartum nurse that the client ambulated to the bathroom without difficulty and voided just prior to being transferred. An initial assessment is completed by the postpartum nurse. Where will the nurse expect to palpate the uterine fundus? a) Midline at the umbilicus. b) Midline 2 cm above the umbilicus. c) Shifted left at the umbilicus. d) Shifted right 4 cm below umbilicus.

a) Midline at the umbilicus. The uterine fundus should be midline at the umbilicus after birth for 24 hours. A fundus elevated above the umbilicus or shifted to the left or right may indicate blood in the uterus or a full bladder.

The client asks the nurse why the insulin was discontinued after the baby was born and asks if she will have to take a shot or a pill now. The nurse's response should be based on which information? a) Most women with gestational diabetes return to normal glucose levels after birth. b) Sliding scale insulin will be needed for 6 weeks postpartum. c) Breastfeeding increases the need for insulin so an insulin pump will be applied. d) Oral hypoglycemics will be started as soon as the client is eating a regular diet.

a) Most women with gestational diabetes return to normal glucose levels after birth. Because the major source of insulin resistance, the placenta, is gone after birth, the woman with gestational diabetes usually returns to normal glucose levels and requires no insulin, oral hypoglycemics, or diabetic diet. Breastfeeding also decreases insulin needs because of the carbohydrates used in human milk production.

Two hours later, the client is 6 cm dilated. She requests pain medication to "take the edge off" the contractions, but she does not want an epidural. The nurse calls the obstetrician and receives a prescription for butorphanol tartrate 1 mg IV. Which assessment information is most important for the nurse to validate with the laboring client before giving the medication? a) Past or present history of opioid dependence. b) Length of all previous labor experiences. c) Herbal preparation use during pregnancy. d) Previous use of analgesia or anesthesia in labor.

a) Past or present history of opioid dependence. Butorphanol tartrate is an opioid agonist-antagonist. Respiratory depression, nausea, and vomiting occur less often with this group of drugs when compared with opioid agonists. However, because butorphanol tartrate also acts as an antagonist, it is not suitable for women with a history of opioid dependence because it can precipitate withdrawal symptoms (abstinence syndrome) in both the mother and the neonate.

As the nurse performs the intervention, the obstetrician cuts an episiotomy. The client pushes and the male infant is born. He weighs 9 lbs 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes, requiring only stimulation and bulb suctioning. The nurse performs a physical assessment of the newborn prior to giving him to his mother to breastfeed. Click for Image Which newborn behavior indicates to the nurse that the infant has suffered a complication from the shoulder dystocia? a) Unilateral absence of the Moro reflex. b) One eye remains open when crying. c) Positive Babinski reflex bilaterally. d) Presence of caput succedaneum.

a) Unilateral absence of the Moro reflex. This behavior is indicative of a fractured clavicle, which is a common complication of shoulder dystocia. Newborn fractures heal rapidly and immobilization is accomplished with slings, splints, or sometimes simple swaddling.

Management Issues Two hours after her delivery, the labor and delivery nurse notifies the postpartum charge nurse that the client and her son will be transferred to the unit. The charge nurse is also notified that three other mother-infant couplets will be transferred at about the same time. The postpartum unit is staffed with a new graduate nurse who has completed orientation, a nurse with 3 years' experience, an nurse with 10 years' experience, and a Licensed Practical Nurse (LPN) with 20 years' experience. Which client should the charge nurse assign the LPN? a) The client who is a gestational diabetic and had a problem breastfeeding. b) A multigravida who had an uncomplicated term delivery and is breastfeeding. c) A primigravida who had a cesarean delivery 4 hours ago and is bottle feeding. d) A primigravida who is 12 hours posteclamptic seizure and is bottle feeding.

b) A multigravida who had an uncomplicated term delivery and is breastfeeding. Once the initial assessment is done, the LPN is qualified to care for this client because there are no complications expected.

The client has a nonreactive nonstress test. She is taken to the ultrasound department for completion of the BPP, and her total score is 6 (Fetal Breathing Movements = 2, Gross Body Movements = 0, Fetal Tone = 2, Nonreactive Nonstress Test = 0, and Qualitative Amniotic Fluid Volume = 2). On the basis of this score, the obstetrician recommends that an amniocentesis be completed to assess for fetal lung maturity before a decision is made whether to induce delivery for the client the following day. Prior to the amniocentesis, which action should the nurse take first? a) Administer Rh immune globulin if client is Rh negative. b) Assist the client to the bathroom and ask her to empty her bladder. c) Apply the external fetal monitor to evaluate uterine contractility. d) Clean the abdomen with betadine solution and sterile 4 by 4s.

b) Assist the client to the bathroom and ask her to empty her bladder. In late pregnancy, this should be done first to decrease the risk of accidental bladder puncture during the procedure. In early pregnancy the bladder should be full when an amniocentesis is done for genetic studies.

The nurse notes that the client's fasting one-hour glucose screening level from last week is 164 mg/dL. Which information does the nurse recognize in the client's history to support a diagnosis of gestational diabetes? a) Maternal great-aunt has non-insulin dependent (Type 2) diabetes b) Child weighed 9 lbs (4.08 kg) at 41 weeks' gestation c) Trace of protein noted in urine specimen at last prenatal visit d) Client is 64 in (1.63 m) tall and weighed 134 lbs (60.78 kgs) prior to pregnancy

b) Child weighed 9 lbs (4.08 kg) at 41 weeks' gestation Birth of an infant weighing more than 9 lbs (4.08 kg) is a risk factor for gestational diabetes. Other risk factors include maternal age older than 25, obesity, history of unexplained stillborn, family history of Type 1 diabetes in a first-degree relative, strong family history of Type 2 diabetes, and history of gestational diabetes in a previous pregnancy. Ethnic groups at increased risk include Hispanic, Native-American, Asian, and African-American.

After all of her questions are answered, the client is scheduled for a return visit with the obstetrician in 1 week, and she is escorted to the office of the Registered Dietician (RD). The RD discusses the need to control carbohydrates while maintaining an appropriate carbohydrate-protein-fat ratio to promote consistent weight gain (based on the client's body mass index), prevent ketoacidosis, and encourage normoglycemia (euglycemia). The client is then introduced to the diabetes educator. She asks the nurse to clarify what the RD told her about the content and timing of her meals. Which responses should the nurse give to the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply a) Eliminate the bedtime snack if heartburn develops after eating b) Choose complex carbohydrates that are high in fiber content c) Increase the percentage of protein in the diet if anemia develops d) Avoid foods high in refined sugars e) Drink between 8 to 10 cups of fluid daily

b) Choose complex carbohydrates that are high in fiber content d) Avoid foods high in refined sugars e) Drink between 8 to 10 cups of fluid daily

Further Glucose Screening The client is scheduled for a 3-hour oral glucose tolerance test in 5 days and is told to arrive at the lab at 8:30 am. The client asks if there are any special instructions for the test in addition to fasting for 8 hours immediately prior to the test. Which instruction should the nurse give the client? a) Only coffee or tea is allowed once the fasting level has been drawn b) Follow an unrestricted diet and exercise pattern for at least 3 days before the test c) Write down questions and call the laboratory for instructions the day before the test d) Smoking in moderation is allowed up until the time the test begins

b) Follow an unrestricted diet and exercise pattern for at least 3 days before the test When the client follows an unrestricted diet (including at least 150 g of carbohydrates) and regular exercise patterns, the test is a true determination of the body's ability to handle the glucose load given after the fasting blood glucose is drawn.

Two days later, the client and her infant are both stable and breastfeeding is well established. The nurse is preparing discharge teaching and notes that the client has chosen to use the progestin-only birth control pill beginning at 6 weeks postpartum and that she plans to breastfeed exclusively for at least 6 months. Which information is most important for the nurse to discuss concerning the use of contraception while breast feeding? (Select all that apply. One, some, or all options may be correct.) Select all that apply a) Irregular vaginal bleeding (breakthrough bleeding) is not unusual when using this medication and usually lessens over time. b) If a dose is taken more than 3 hours late, a backup method of birth control must be used for the next 48 hours. c) It is important to notify laboratory personnel that this medication is being used because it alters the results of certain tests. d) It is important to use another method of contraception prior to starting the Mini Pill. e) The medication may be taken with food if the side effect of nausea occurs when ingested on an empty stomach.

b) If a dose is taken more than 3 hours late, a backup method of birth control must be used for the next 48 hours. d) It is important to use another method of contraception prior to starting the Mini Pill. Because this medication contains such a low dose of progestin, it should be taken at exactly the same time every day; if this is not done, the risk of pregnancy increases at a much greater rate than if one misses a combined estrogen-progestin pill. Breastfeeding can suppress fertility, but it is important to understand that as soon as there is a decline in breastfeeding, the contraceptive protection decreases and other non-pharmacological methods should be considered.

The nurse notes what time the head delivered and assists with the initial intervention for the shoulder dystocia. The obstetrician is still having difficulty delivering the shoulders. Which of the following actions should the nurse be prepared for at this time? a) Elevate the hips with pillows. b) Apply fundal pressure. c) Position the client in Trendelenburg. d) Apply suprapubic pressure.

d) Apply suprapubic pressure. Suprapubic pressure pushes the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis

The diabetes educator makes a plan of care to teach the client to monitor her glucose levels. The diabetes educator discusses the use of self-glucose monitoring and gives the client verbal and written guidance about optimal glucose levels at each glucose testing point throughout the day. The nurse also provides instructions about calibration of the glucose monitor, fingerstick technique, and use of the monitor for testing. After a review of the instructions and a successful return demonstration by the client, they agree to meet after the client's prenatal appointment to follow up on the teaching/learning Which instructions should the diabetes educator include regarding when to perform fingerstick blood glucose (FSBG) monitoring? a) Check fasting blood sugar at lunch time b) Perform blood glucose monitoring prior to breakfast (fasting) and before each meal. c) Two hours after all meals, at bedtime, and in the middle of the night d) Once a day at dinner time

b) Perform blood glucose monitoring prior to breakfast (fasting) and before each meal. This protocol will identify if the prescribed diet is promoting euglycemia, and the record obtained from it will allow the healthcare provider and RD to make changes in the plan of care as needed.

As the charge nurse walks down the hall to tell the nurses about the new admissions, she hears one of the nurses giving misinformation about the Rh immune globulin injection to a client and her husband. Which information should the nurse give about the Rh immune globulin injection? a) Rh immune globulin is given to the infant within 48 hours of delivery. b) Rh immune globulin is given to the mother within 72 hours of delivery, if the infant is Rh-positive. c) Rh immune globulin is a vaccine given to a mother with Rh-positive blood within 24 hours of delivery. d) Rh immune globulin is given at 18 weeks gestation to mothers with Rh-negative blood.

b) Rh immune globulin is given to the mother within 72 hours of delivery, if the infant is Rh-positive. Rh immune globulin is given to a mother who has Rh-negative blood and the infant is Rh-positive. It is given within 72 hours of delivery.

Danielle's husband arrives to be her labor coach and is surprised to learn that Danielle needs IV insulin an dis being so closely monitored. He tells the labor nurse he vaguely remembers the obstetrician discussing the possible need for insulin at a prenatal visit, but he is uncertain why the blood sugar is being maintained between 70 and 90 mg/dL. The nurse's response should be based on what information? a) More insulin will be available for fetal use via placental transfer b) A glucose level more than 90 to 100 puts the client at risk for infection in labor c) An elevated glucose in labor increases the risk of neonatal hypoglycemia. d) Maintaining euglycemia in labor decreases the need for insulin postpartum.

c) An elevated glucose in labor increases the risk of neonatal hypoglycemia. Maternal glucose crosses the placenta and the fetus responds by making insulin. Over time, hyperplasia of the fetal pancreas occurs with subsequent hyperinsulinemia. When the maternal source of glucose disappears at delivery, the neonate's blood glucose level decreases rapidly in the presence of fetal hyperinsulinemia.

The newborn's assessment is normal. The client breastfed her other children, but is concerned because she read that infants of diabetic mothers are at greater risk for jaundice than infants of nondiabetic mothers. She is also worried about the infant developing hypoglycemia. What should the nurse recommend to the client in regard to infant feeding? a) The infant requires formula to prevent hypoglycemia and jaundice. b) The newborn needs breast milk and 5% dextrose water. c) Breastfeeding should be initiated immediately and done on demand. d) A mixture of breastmilk and formula will prevent complications.

c) Breastfeeding should be initiated immediately and done on demand. Breastfeeding that commences early and is done on demand (breastfeeding infants generally feed more often than formula-fed infants) helps decrease the risk of hypoglycemia and jaundice. Supplements of water and/or formula are not needed.

The client asks the nurse why she wasn't tested for gestational diabetes until she was at almost 28 weeks gestation. The nurse's response should be based on the understanding of which normal physiologic change of pregnancy? a) Maternal insulin crosses the placenta to regulate fetal glucose levels throughout pregnancy b) In the first trimester, estrogen and progesterone cause an increase in maternal fasting glucose levels c) Hormonal changes in the second and third trimesters result in increased maternal insulin resistance d) Fetal insulin production increases each trimester, forcing the mother's body to produce more glucose

c) Hormonal changes in the second and third trimesters result in increased maternal insulin resistance. Increased levels of hormones increase insulin resistance because they act as insulin antagonists. This serves as a glucose-sparing mechanism to ensure an adequate glucose supply to the fetus. While most pregnant women's bodies are able to handle this insulin resistance, women with gestational diabetes cannot and therefore demonstrate an impaired tolerance to glucose during pregnancy and develop hyperglycemia.

Legal Issues The client tells the nurse that she would like to receive one-half of the prescribed dose of butorphanol tartrate because the last time she was given that medication she felt like she was floating and then experienced some confusion. Which action should the nurse take? a) Administer one-half of the dose as requested. b) Tell the client that she must take the whole dose. c) Request that the obstetrician change the prescription. d) Substitute a medication with fewer side effects.

c) Request that the obstetrician change the prescription. The nurse should consult the obstetrician if the nurse believes a prescription should be altered. The nurse cannot reduce a medication dose without consulting the obstetrician, even at the client's request.

The client and her fetus are monitored for 2 hours after the procedure and display no adverse effects, so the external fetal monitor is discontinued. The amniocentesis reveals fetal lung maturity and an induction is scheduled for the next morning. At 2 a.m., she complains of increased uterine discomfort and is contracting every 10 minutes. While the antepartum nurse is in the room, the client's membranes rupture spontaneously. Which action by the nurse takes "priority"? a. Notify the obstetrician of the changes in the client's status. b. Transfer the client to the labor-delivery-recovery (LDR) suites. c. Reapply the external fetal monitor to evaluate the fetal heart rate. d. Start an intravenous line using an 18-gauge or larger intravenous catheter.

c. Reapply the external fetal monitor to evaluate the fetal heart rate. The response of the fetus to the rupture of the membranes should be evaluated immediately due to the risk of cord prolapse. The nurse will also assess and document the color, amount, viscosity, and odor of the amniotic fluid.

Care During Birth The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate continues to be reassuring with a baseline of 145 and moderate variability present. The nurse briefly reviews pushing techniques with the client and her spouse and notifies the obstetrician of the client's progress. The obstetrician is at the bedside and is prepared for delivery. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum but rotates externally and retracts back against the perineum. The nurse and obstetrician recognize these signs as an indication of shoulder dystocia. Which immediate action should the nurse take? a) Notify the operating room to prepare for a cesarean section. b) Apply external pressure to the uterine fundus. c) Administer 0.25 mg terbutaline subcutaneously. d) Reposition the client using McRobert's maneuver.

d) Reposition the client using McRobert's maneuver. The nurse should assist the woman in flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position decreases the angle of the pelvic inclination, rotates the symphysis pubis toward the maternal head, and causes the sacrum to straighten, freeing the shoulder. This maneuver is often combined with suprapubic pressure, which also helps free the shoulder from under the symphysis p

A Complication Occurs The client manages her gestational diabetes with diet. She experiences a few episodes of postprandial hyperglycemia but does not have to take insulin. At her 36-week prenatal visit, the obstetrician assesses the client and finds that there is no increase in fetal growth since the previous week. When questioned further, she tells the obstetrician that the fetus seems to have slowed down a little the last few days. The client is scheduled for a biophysical profile (BPP) and is admitted to the hospital's antepartum unit. The antepartum nurse performs a nonstress test (NST) as part of the BPP. Which fetal heart rate (FHR) changes indicate a reactive nonstress test? 1. a) Persistent late decelerations associated with three uterine contractions, lasting 40 to 60 seconds each in a 10-minute period b) An increase in the FHR baseline to 170 beats per minute, lasting for at least 20 minutes c) Marked FHR variability in response to contractions caused by nipple stimulation d) Two episodes of acceleration (Greater than 15 beats/minute, lasting more than 15 seconds) related to fetal movement in a 20-minute period

d) Two episodes of acceleration (Greater than 15 beats/minute, lasting more than 15 seconds) related to fetal movement in a 20-minute period This describes a reactive nonstress test. The test is based on the premise that the normal fetus with an intact central nervous system (CNS) will produce accelerations of the fetal heart rate in response to 90% of gross fetal body movements. When used as part of the BPP, a reactive test is worth 2 points, and a nonreactive test is worth 0 points.