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

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

I.V. fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and I.V. 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 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.

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.

A pregnant client is diagnosed with syphilis. Which interviewing question 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 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.

Which initial interview technique would be least effective in gathering information from a suspected abuse victim?

Ask the client to strip down and show you where she has been hurt. When interviewing a suspected abuse victim initially, the nurse needs to be supportive and respectful of her. Always talk to the victim alone and in a private place. Ask simple, direct, open-ended questions that allow the client to describe her experiences. Never imply that the woman is in any way responsible for the abuse by asking questions about why she stays with the abuser or what she did to make him mad. Never ask the client to strip for you to inspect her body initially. The nurse needs to establish a rapport with the woman first so trust can be established.

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 non-judgmental 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.

The nurse encourages a woman with gestational diabetes to maintain an active exercise period during pregnancy. Prior to this exercise period, the nurse would advise her to take which action?

Eat a sustaining-carbohydrate snack. Because exercise uses up glucose, women with diabetes should take a sustaining-carbohydrate snack before hard exercise to prevent hypoglycemia.

A pregnant client with diabetes in the hospital reports waking up with shakiness and diaphoresis. Which action should the nurse prioritize after discovering the client's fasting blood sugar is 60 mg/dL?

Provide the client some milk to drink. The client is hypoglycemic when awakening in the morning. The nurse should provide glucose in the form of carbohydrate, such as crackers, and milk, and be prepared to reassess. The nurse should not recheck at this point, since the client is symptomatic. She does not need insulin, and she will have her morning dose adjusted after breakfast.

A young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity?

breastfeeding Breastfeeding is a major contributing factor for mother-to-child transmission of HIV. Cesarean birth before the onset of labor and/or rupture of membranes can greatly reduce the chance of transmitting the infection to the infant. Future pregnancies should be discussed and decided on an individual basis. Proper treatment of any open wounds and education should be provided to the mother to ensure she reduces the chance of transmitting HIV to her infant.

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.

A client in her fifth month of pregnancy is having a routine clinic visit. The nurse should assess the client for which common second trimester condition?

physiological anemia Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. Mastitis is an infection in the breast characterized by a swollen tender breast and flu-like symptoms. This condition is most commonly seen in breastfeeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.

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 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.

A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement?

"A pregnant woman does not have to worry about contracting new illnesses during pregnancy." When a woman enters a pregnancy with a chronic illness, it can put both her and the fetus at risk. She needs to be cautious about developing a new illness during her pregnancy as well as having an accident during the pregnancy.

The nurse instructs a pregnant patient with sickle cell anemia on ways to prevent a crisis. Which patient statement indicates that teaching has been effective?

"I should drink eight glasses of water every day." The fluid status of a pregnant patient with sickle-cell anemia is important because dehydration can precipitate a crisis. The patient should drink at least eight glasses of fluid each day to prevent dehydration. Patients with sickle-cell anemia should not take an iron supplement because the sickled cells cannot incorporate iron in the same way as nonsickled cells. Standing for long periods of time can cause red cell destruction in the patient with sickle-cell anemia. The patient should sit with the legs elevated to encourage venous return of blood from the lower extremities.

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.

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 sugars are 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 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 increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

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

Increased risk of development of 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.

The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation?

Jugular distention A woman who has a cardiac condition is at increased risk in the postpartum period. The most important nursing action is to monitor for signs of cardiac decompensation. The nurse should monitor for and report jugular distention, clubbing, and slow capillary refill time. If an irregular pulse is noted, compare it to the apical pulse. The abdominal cramps may be related to the uterus involution. The nausea and vomiting and urinary retention may be related to the surgical procedure and not necessarily the cardiac issue.

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 follow stressing 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.

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 caring for a pregnant client suspected 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, abortion, 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.

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 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.

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.

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low birth weight infant The partner answers questions for the pregnant client. Intimate partner violence (IPV) occurs in both heterosexual as well as same-sex relationships. The nurse needs to be on the lookout for signs of violence when caring for women. It is estimated that 4% to 8% of pregnant women experience abuse during the pregnancy. Signs include a passive or quiet client who may appear unkempt or depressed. The abuser often refuses to leave the client alone with the health care providers and answers questions posed to the mother. The abuser is often overly protective of the client. Consequences of abuse include poor weight gain during the pregnancy, late entry into prenatal care, preterm labor and fetal death.

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 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 of 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.

A nurse is client teaching with 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.

The nurse is teaching a pregnant woman with iron-deficiency anemia about her prescribed iron supplement. The nurse determines that the teaching was successful when the client states that she will take the supplement with:

citrus juice. Iron absorption is enhanced when taken with foods high in vitamin C, such as citrus juice. Foods such as coffee, tea, and those high in fiber should be avoided.

A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:

check her blood sugars frequently and adjust insulin accordingly. The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.

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 providing care to a neonate. Review of the maternal history reveals that the mother is suspected of abusing heroin. The nurse would be alert for which finding when assessing the neonate?

hypertonicity Newborns of mothers who abuse heroin or other narcotics display irritability, hypertonicity, a high-pitched cry, vomiting, diarrhea, respiratory distress, disturbed sleeping, sneezing, diaphoresis, fever, poor sucking, tremors, and seizures.

Over the past 20 weeks, the following blood pressure readings are documented for a pregnant client with chronic hypertension: week 16 - 124/86 mm Hg; week 20 - 138/90 mm Hg; week 24 - 140/92 mm Hg; and week 28 - 142/94 mm Hg. The nurse interprets these findings as indicating which classification of her blood pressure?

mild hypertensive 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. It has been classified as normotensive (systolic less than 120 mm Hg, diastolic less than 80 mm Hg); prehypertension (systolic 120 to 139 mm Hg, diastolic 80 to 89 mm Hg); mild hypertension (systolic 140 to 159 mm Hg, diastolic 90 to 99 mm Hg); and severe hypertension (systolic 160 mm Hg or higher, diastolic 100 mm Hg or higher).

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 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 substance abuse during pregnancy. Complimentary therapies like ginger therapy help in the alleviation of hyperemesis gravidarum not peripartum cardiomyopathy.

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.

A woman at 26 weeks' gestation is undergoing screening for diabetes with a 1-hour oral glucose challenge test. On the client's return visit, the nurse anticipates the need to schedule a 3-hour glucose challenge test based on which result of the previous test?

146 mg/dL For a 1-hour glucose challenge test, a 75-g oral glucose load is given, without regard to the timing or content of the last meal. Blood glucose is measured 1 hour later; a level above 140 mg/dL is abnormal. If the result is abnormal, a 3-hour glucose tolerance test is done.

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 indurated wheal over 10 mm 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 pregnant woman with diabetes is having her glycosylated hemoglobin 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 glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level of more than 8.0% indicates poor blood glucose control and the need for intervention, necessitating a revision in the woman's plan of care.

A client is 33 weeks pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled?

85 mg/dL Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dL. A fasting blood glucose level of 45 g/dL is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dL is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL in a pregnant client indicates hyperglycemia.

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.

A postpartum patient with systemic lupus erythematosus asks why symptoms of the disease are worse now that the baby has been born. What should the nurse explain to the patient?

Symptoms may be worse because corticosteroid levels are returning to normal. During the postpartum period, there may be an acute exacerbation of systemic lupus erythematosus symptoms because corticosteroid levels are returning to normal. Symptoms are not increased because the fetus was keeping the symptoms in check. The stress of delivery is not causing the symptoms to increase. The symptoms are not because of a spike in maternal hormone levels.

The nurse is caring for a patient who desires to become pregnant within a few months. Which outcome regarding folic acid intake would be appropriate for this patient?

The client will begin taking 400 μg of folic acid every day. All patients expecting to become pregnant are advised to begin a supplement of 400 μg folic acid daily in addition to eating foods rich in folic acid. The folic acid supplement is not needed with each meal. Foods high in folic acid should be consumed in addition to the supplement. The patient should take folic acid supplements before becoming pregnant and not wait until pregnancy is confirmed.

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.

A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be:

antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn. Antiepileptic therapy may cause vitamin K-deficient hemorrhage of the newborn that the vitamin K injection the newborn receives following birth cannot fully correct. Therefore, some physicians recommend a Vitamin K supplement for their pregnant patients beginning at 36 weeks' gestation. If the mother should go into preterm labor, the newborn will have received the vitamin K prior to delivery. However, many physicians now question the usefulness of the prophylaxis.

A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this disease make her infant at risk for?

blindness A pregnant woman who contracts chlamydia is at increased risk for spontaneous abortion (miscarriage), preterm rupture of membranes, and preterm labor. The postpartum woman is at higher risk for endometritis (Fletcher & Ball, 2006). The fetus can encounter bacteria in the vagina during the birth process. If this happens, the newborn can develop pneumonia or conjunctivitis that can lead to blindness.

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 daycare centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breast-feeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.

During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn?

respiratory function The nurse should identify respiratory distress syndrome as a major risk that can be faced by the offspring of a client with cardiovascular disease. While the other assessments are important, they are not priority.