Ch 20 Nursing Care of a Family Experiencing a Pregnancy Complication From a Preexisting or Newly Acquired Illness

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 providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?

She is at increased risk for type 2 diabetes mellitus after her baby is born. The woman who develops GDM is at increased risk for developing type 2 diabetes mellitus after pregnancy.

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source?

complex carbohydrates The pregnant woman with diabetes is encouraged to eat three meals a day plus three snacks, with 40% of calories derived from good-quality complex carbohydrates, 35% of calories from protein sources, and 35% of calories from unsaturated fats. The intake of saturated fats should be limited during pregnancy, just as they should be for any person to reduce the risk of heart disease.

The maternal health nurse is caring for a pregnant client with a history of epilepsy. The client's antiepileptic drug (AED) levels have been in the non-therapeutic range the last two times the labs were drawn. Which factor does the nurse associate with this finding?

Drug metabolism changes during pregnancy Drug metabolism changes during pregnancy which may alter the therapeutic AED levels in the pregnant client. Some AEDs cannot be given in pregnancy due to risk of harm to the fetus; however, there are some that may be given. Pregnant clients do not have high rates of noncompliance and the action of medications do not change in pregnancy.

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 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 assessing a client in her seventh month of pregnancy who has an artificial valve prosthesis. The client is taking an oral anticoagulant to prevent the formation of clots at the valve site. Which of the following nursing interventions is most appropriate in this situation?

Observe the client for signs of petechiae and premature separation of the placenta Subclinical bleeding from continuous anticoagulant therapy in the woman has the potential to cause placental dislodgement. Observe a woman who is taking an anticoagulant for signs of petechiae and signs of premature separation of the placenta, therefore, during both pregnancy and labor. The nurse should not urge the client to discontinue the anticoagulant, as this is not within the nurse's scope of practice and, in any case, the client still needs the anticoagulant to prevent clots. Bed rest is prescribed for clients with a thrombus, to prevent it from moving and becoming a pulmonary embolus. Avoiding the use of constrictive knee-high stockings is to prevent thrombus formation.

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy would the nurse expect to administer to the client?

restricted sodium intake The client with peripartum cardiomyopathy should be prescribed a restricted sodium intake to control the blood pressure. Monoamine oxidase inhibitors are given to treat depression in pregnancy, not peripartum cardiomyopathy. Methadone is a drug given for the treatment of a substance use disorder during pregnancy. Complementary therapies like ginger therapy help in the alleviation of hyperemesis gravidarum, not peripartum cardiomyopathy.

A pregnant woman who has been taking penicillin prophylactically because she had rheumatic fever as a child tells the nurse that she wants to stop taking it now that she is pregnant. Which of the following is the best response by the nurse?

"You should continue taking this drug, because penicillin is not known to be a fetal teratogen." A woman taking penicillin prophylactically because she had rheumatic fever as a child and wants to prevent a recurrence should continue this drug during pregnancy. Penicillin is not known to be a teratogen.

The nurse is caring for a pregnant woman determined to be at high risk for gestational diabetes. The nurse prepares to rescreen this client at which time frame?

24 to 28 weeks A woman identified as high risk for gestational diabetes would undergo rescreening between 24 and 28 weeks; however, some health care providers can choose to conduct this screening earlier.

The nurse is assessing a pregnant client who has a history of heart disease. The nurse will prioritize assessments focusing on the heart during which time frame?

28 to 32 weeks' gestation A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation, just after the blood volume peaks. It would be important to assess the client's heart at each visit; however, the client's heart would be more stressed at this time due to the increased blood volume and identifying a serious situation early provides the best opportunity for treatment and preventing complications.

A 38-year-old woman comes into the obstetrician's office for prenatal care, stating that she is about 12 weeks pregnant with her first child. What questions would the nurse ask this client, considering her age and potential sensitivity to being labeled an "older" primipara?

Be nonjudgmental in your history gathering and offer her pregnancy resources to read and explore. Women are having babies later in life and nurses must be supportive of their choices to postpone pregnancy. Most women realize the increased risks for having a baby after 35 years of age and don't need constant reminding of all the potentially bad outcomes that can occur. The majority of pregnancies to women over 35 years of age end up with healthy babies and mothers.

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.

A pregnant client with deep vein thrombosis has been diagnosed as having systemic lupus erythematosus (SLE). The nurse would monitor the client closely for the development of which complication?

Fetal malnutrition SLE is an autoimmune disorder in which there is deposition of immune complexes in the capillaries and visceral structures. Clients with SLE who become pregnant are at an increased risk of fetal malnutrition due to decreased placental circulation. Pregnancy-related problems in SLE include prematurity, stillbirth, decreased placental weight and thinner placental villi. In clients with SLE there is preterm birth and decreased placental weight. Fetal macrosomia is seen in clients having gestational diabetes, not SLE.

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.

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.

A pregnant client with cystic fibrosis (CF) comes to the office for a prenatal visit. She asks the nurse for information on breast-feeding. The best response by the nurse is:

"Breast-feeding is not a good idea. Because your breast milk is high in sodium due to CF, there is a risk of the infant receiving too much sodium." The milk of a nursing mother with cystic fibrosis is high in sodium. This potentially places the infant at risk for hypernatremia, that is, too much sodium. Provide the client with as much correct information as possible, and explain medical terms in layperson's language.

A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client would the nurse prioritize?

"I sometimes get a bit wheezy." Wheezing is a classic symptom of asthma. This statement should alert the nurse to the possibility that the woman's asthma is not being well-controlled and needs further evaluation and possible intervention. The other statements do not relate to the typical presentation of this disease in pregnancy.

A client in week 38 of her pregnancy arrives at the emergency room reporting a sharp pain between her umbilicus and the iliac crest in her lower right abdomen that is increasing. She reports having experienced intense nausea and vomiting for the past 3 hours. Given these symptoms, the nurse suspects which of the following conditions?

Appendicitis With appendicitis, the nausea and vomiting is much more intense than with morning sickness and the pain is sharp and localized at McBurney's point (a point halfway between the umbilicus and the iliac crest on the lower right abdomen). With a ruptured ectopic pregnancy, a woman may experience abdominal pain that is either diffuse or sharp, but it is less likely to occur precisely at McBurney's point. The symptoms described do not match those of pulmonary embolism or left-sided heart failure.

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 17-year-old primigravida with type 1 diabetes is at 37 weeks' gestation comes to the clinic for an evaluation. The nurse notes her blood sugar has been poorly controlled and the health care provider is suspecting the fetus has macrosomia. The nurse predicts which step will be completed next?

Preparing for amniocentesis and fetal lung maturity assessment If the infant has macrosomia, is large for gestation age, and the mother has had poor blood-sugar control, the provider will want further information on the fetus and readiness for delivery before making any decisions on delivery. After determining the readiness of the fetus, then plans for delivery can be determined and scheduled.

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.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?

congenital anomalies A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or placental abruption (abruptio placentae).

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 your 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 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 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?

"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet." Any woman with epilepsy needs to discuss the medication management with her provider. The current research indicates the medications used for epileptic management are the major cause of birth defects for these patients. The nurse should be careful about mentioning that some epileptics are teratogenic; some women may stop taking their medications in order to get pregnant. Suggesting adoption is inappropriate as the mother has given no indication she is interested in adoption; also, the mother needs to discuss this with the physician so that she can get accurate information about being on anti-seizure medications and being pregnant. The nurse should not share personal information as it does not assist this client in making a serious decision. The client should be referred to the health care provider to help the client make the best decision.

A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize?

IV fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and IV fluids. Antihypertensive drugs usually aren't necessary. Diuretics would not be used unless fluid overload resulted. The client would be given antibiotics only if there were evidence of an infection.

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 nursing instructor is teaching students about caring for a pregnant patient with a pre-existing disease. Which of the following does the instructor suggest has added to an increased incidence of pregnant women with a pre-existing disease?

More women waiting until after age 30 years to get pregnant As more women wait until they are older than 30 years to have their first child, more also enter pregnancy with a pre-existing disorder.

A woman with known cardiac disease from childhood presents at the obstetrician's office 6 weeks' pregnant. What recommendations would the nurse make to the client to address the known cardiac problems for this pregnancy? Select all that apply.

Plan periods of rest into the workday. Receive pneumococcal and influenza vaccines. Let the physician know if you become short of breath or have a nighttime cough. Women with known heart conditions need to be closely followed by both the obstetrician and a cardiologist. Recommendations would include rest periods, reduction of stress, getting immunizations, and monitoring for heart failure as demonstrated by a nighttime cough and shortness of breath. Consuming more sodium in the diet is not recommended due of the potential of developing hypertension. Warfarin is contraindicated during pregnancy since it crosses the placental barrier and can cause spontaneous abortion, stillbirth or preterm birth.

A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider suspects the infant has macrosomia based on the recent ultrasound?

Prepare for assessment of fetal lung maturity. If the infant has macrosomia, is large for gestational age, and the mother has had poor blood sugar control, the provider will want further information on the fetus and readiness for delivery before making any decisions on delivery. This will best be accomplished by an amniocentesis to assess the fetal lung maturity. Scheduling an induction of labor, allowing the patient to continue without plans for delivery, or scheduling a cesarean delivery at 39 weeks would not be appropriate nursing actions. Scheduling an induction or a cesarean section is not in the province of a nurse without a physician's order.

A pregnant woman with a history of mitral valve stenosis is to be prescribed medication as treatment. Which medication class would the nurse expect the client to be prescribed?

anticoagulant In mitral valve stenosis, it is difficult for blood to leave the left atrium. A secondary problem of thrombus formation may develop as a result of noncirculating blood. A woman may need to be prescribed an anticoagulant to prevent this complication. Vasodilators are used for peripartum cardiomyopathy. Inotropics are used for heart failure. Angiotensin receptor blockers are used for congestive heart failure.

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 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

diet Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are contraindicated in pregnancy. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

The health care provider of a newly pregnant client determines the woman also has mitral stenosis and will need appropriate therapy. Which medication should the nurse prepare to teach this client to provide her with the best possible care?

heparin This client has an increased risk for developing blood clots. If an anticoagulant is required, heparin is the drug of choice as it does not cross the placenta barrier. Warfarin crosses the placenta and may have teratogenic effects. Aspirin is not recommended in this situation. Digoxin is not used to prevent blood clots.

A nurse informs a pregnant woman with cardiac disease that she will need two rest periods each day and a full night's sleep. The nurse further instructs the client that which position for this rest is best?

left lateral recumbent The pregnant woman should rest in the left lateral recumbent position to prevent supine hypotension syndrome and increased heart effort.

Which factor would contribute to a high-risk pregnancy?

type 1 diabetes A woman with a history of diabetes has an increased risk for perinatal complications, including hypertension, preeclampsia, and neonatal hypoglycemia. The age of 33 without other risk factors does not increase risk, nor does type O-positive blood or environmental allergens.

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful?

"Pregnancy affects insulin production, so I'll need to make adjustments in my diet." In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.

The nurse is caring for a pregnant client with pregestational diabetes. Which goal does the nurse identify as priority during the client's pregnancy?

Maintain glycemic control The most important goal when caring for a pregnant client with pregestational diabetes is to maintain glycemic control. The scenario does not give enough information on the client's weight to determine if the client should gain only minimal weight during pregnancy. Ensuring compliance of glucose monitoring and monitoring for associated complications are appropriate nursing interventions; however, these do not take priority.

A young woman with scoliosis has just learned that she is pregnant. Several years ago, she had stainless-steel rods surgically implanted on both sides of her vertebrae to strengthen and straighten her spine. However, her pelvis is unaffected by the condition. Which of the following does the nurse anticipate in this woman's pregnancy?

Potential for greater than usual back pain Surgical correction of scoliosis (lateral curvature of the spine) involves implanting stainless-steel rods on both sides of the vertebrae to strengthen and straighten the spine. Such rod implantations do not interfere with pregnancy; a woman may notice more than usual back pain, however, from increased tension on back muscles. If a woman's pelvis is distorted due to scoliosis, a cesarean birth may be scheduled to ensure a safe birth, but this is not required in this scenario. Vaginal birth, if permitted, requires the same management as for any woman. With the improved management of scoliosis, the high maternal and perinatal risks associated with the disorder reported in earlier literature no longer exist.

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 caring for a pregnant woman with diabetes mellitus. Which potential fetal complications should the nurse monitor the client for as she presents for her scheduled visits? Select all that apply.

congenital malformations macrosomia respiratory disorder Potential problems during pregnancy involving maternal diabetes mellitus include fetal death, macrosomia (oversized fetus), a fetus with a respiratory disorder, difficult labor, preeclampsia or eclampsia, polyhydramnios, and congenital malformations.

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.

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.

In women with cardiac failure, the maternal blood pressure becomes insufficient to provide an adequate supply of blood to the placenta. The infant will likely experience some undesired effects, including which of the following?

low birth weight Cardiac failure can affect fetal growth at the point at which maternal blood pressure becomes insufficient to provide an adequate supply of blood and nutrients to the placenta. For this reason, the infant may tend to have a low birth weight, be preterm, and respond poorly to labor.