OB -- Endocrine and Metabolic Disorders

C -- Pregestational diabetes mellitus is a term used to describe type 1 or type 2 diabetic clients in whom the diabetes existed prior to pregnancy. Gestational diabetes occurs when during the pregnancy, a woman becomes diabetic. A type 2 diabetic is non-insulin dependent. This option indicates type 1, or insulin-dependent, diabetes. There is no information presented that indicates complications at this point, because the hemoglobin A1c is within normal range, indicating adequate glycemic control.

A client who is pregnant already has type 2 diabetes and a hemoglobin A1c of 7. What does the nurse would categorize this client as having? a. gestational diabetes b. Insulin-dependent diabetes complicated by pregnancy. c. Pregestational diabetes mellitus d. Non-insulin-dependent diabetes with complications

C -- Fluid, electrolyte, and acid-base imbalances present the greatest immediate danger to the well-being of the mother and fetus and should be corrected as soon as possible. Resting the GI tract and discussing her feelings are components of treatment but are not immediate goals for this client. The ability to retain oral fluid and foods is a longer-term goal of treatment for this condition.

A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. What is the primary goal of her treatment at this time? a. Rest the gastrointestinal (GI) tract by restricting all oral intake for 48 hours. b. Reduce emotional distress by encouraging the woman to discuss her feelings. c. Reverse fluid, electrolyte, and acid-base imbalances. d. Restore the woman's ability to take and retain oral fluid and foods.

D -- Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis. Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative.

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: a. Oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. b. Dietary modifications and insulin are both required for adequate treatment. c. Glucose levels are monitored by testing urine four times a day and at bedtime d. Dietary management involves distributing nutrient requirements over three meals and two or three snacks.

B -- Congenital malformations account for 30% to 50% of perinatal deaths in diabetic pregnancies. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome, and the transition to extrauterine life is often marked by hypoglycemia and other metabolic abnormalities.

Diabetes in pregnancy puts the fetus at risk in several ways. Of what should the nurse be aware regarding this? a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d. At birth, the neonate of a diabetic mother is no longer in any greater risk.

C

During her pregnancy a women with pre gestational diabetes has been monitoring her blood glucose level several times a day. Which level requires further assessment? a) 85 mg/dl - 15 min prior to breakfast b) 90 mg/dl - prior to lunch c) 140 mg/dl - 2 hours after lunch d) 126 mg/dl - 1 hour after supper

A -- Poorly controlled hyperglycemia at the time of conception and early pregnancy often leads to miscarriage. The risk of having a miscarriage increases with the duration and severity of the client's diabetes. Hydramnios occurs in the third trimester of pregnancy in the diabetic client. It may be due to increased glucose concentration in the amniotic fluid from maternal and fetal hyperglycemia, which induces fetal polyuria. Preeclampsia occurs in later pregnancy and in the postpartum period. Pregnant clients with poorly controlled hyperglycemia at the beginning of pregnancy, especially if combined with nephropathy and hypertension, are at higher risk of developing preeclampsia. Ketoacidosis occurs in the second and third trimesters. This is the accumulation of ketones in the body due to hyperglycemia, and it may lead to metabolic acidosis.

For what condition is a client at risk in early pregnancy due to poorly controlled hyperglycemia? A. Miscarriage B. Hydramnios C. Preeclampsia D. Ketoacidosis

A -- Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. "Insulin dosage will likely need to be increased during the second and third trimesters," "Episodes of hypoglycemia are more likely to occur during the first 3 months," and "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding" are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy.

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."

D -- Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Although advanced maternal age may pose some health risks, the most important factor for the woman with pregestational diabetes remains the degree of glycemic control during pregnancy. The number of years since diagnosis and the amount of insulin required are not as relevant to outcomes as the degree of glycemic control.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that which is the most important factor affecting pregnancy outcome? a. mother's age b. number of years since the diabetes was diagnosed c. amount of insulin required prenatally d. degree of glycemic control during pregnancy

B -- Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, 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 types 1 and 2 diabetes.

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

C -- A client who has previously had a microcephalic infant must be screened for undiagnosed homozygous maternal PKU in the first prenatal visit. Toxic accumulation of phenylalanine in the blood due to a lack of the enzyme phenylalanine hydrolase interferes with brain development. The client who had a previous macrosomic fetus must be screened for hyperglycemia. A client with a macrosomic fetus may have obstructed labor. Placental insufficiency may lead to stillbirth. The client who had placental insufficiency in a previous pregnancy need not be screened for PKU.

In which pregnant client does the nurse identify the need to screen for undiagnosed homozygous maternal phenylketonuria (PKU)? A. A client who had a macrosomic fetus in a previous pregnancy B. A client who had obstructed labor in a previous pregnancy C. A client who has given birth to a microcephalic infant D. A patient who had placental insufficiency in a previous pregnancy

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.

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.

C -- Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin 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.

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

C -- Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy.

Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin: A. Increases throughout pregnancy and the postpartum period. B. Decreases throughout pregnancy and the postpartum period. C. Varies depending on the stage of gestation. D. Should not change because the fetus produces its own insulin.

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.

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

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.

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 CNS c. preterm birth d. low birth weight

A -- Diabetic ketoacidosis is a potentially fatal complication of diabetes that can lead to fetal death. This complication may occur if the client's blood glucose levels rise above 200mg/dl. Diabetic ketoacidosis can be confirmed by assessing the presence of ketones in the urine. The client's blood glucose level is 325 mg/dl and, hence, the patient has poorly controlled diabetes. Therefore, the nurse need not assess the urine glucose levels. Arterial blood gases and abdominal ultrasound are not useful for diagnosis of intrauterine fetal death.

The blood glucose level of a pregnant client is 325 mg/dl. Which test should be performed on the patient to assess the risk of maternal or intrauterine fetal death? a. ketones in urine b. glucose in urine c. arterial blood gases d. abdominal U/s

D -- The breastfeeding mother's insulin requirements return to prepregnancy levels after the infant has been completely weaned. At birth, there is a sudden drop in the levels of insulinase following expulsion of the placenta, but they do not return to prepregnancy levels. When the mother is not breastfeeding, the insulin carbohydrate balance returns in 7 to 10 days. Maternal glucose is used up during lactation; therefore the breastfeeding mother's insulin requirement remains low.

The nurse is caring for a diabetic client who is breastfeeding her infant. Within what time frame following childbirth do the client's insulin requirements return to prepregnancy levels? a. immediately after childbirth b. 7-10 days after childbirth c. during the lactation period d. on completion of weaning

A, B, C The White's classification system considers the duration of diabetes in the client. It is based on the age at which the illness was diagnosed. It also considers the involvement of the end-organs, which are the eye and the kidneys. The American Diabetes Association (ADA) classifies diabetes into four mutually exclusive categories. They are type 1, type 2, others, and gestational diabetes. In this classification method, type 1 and type 2 diabetes are further classified into two groups. One group includes those with vascular complications and the other group includes those without vascular complications.

The nurse is using White's classification of diabetes in pregnancy. What are the features of White's classification? Select all that apply. a. It considers the duration of diabetes in the client. b. It is based on the age at which diabetes was diagnosed. c. It is based on the involvement of the eye and the kidneys. d. It classified as type 1, type 2, others, and gestational diabetes. e. It considers two groups with and without vascular complications.

C -- A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood.

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: a. Is now 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. Would be considered evidence of good diabetes control with a result of 5% to 6% d. Is done on the patient's urine, not her blood.

B -- Determination of ketonuria would be a critical assessment that would lead towards determination of hyperemesis. A pregnant patient with severe nausea and vomiting may have hyperemesis gravidarum and as such requires critical monitoring to determine the nature of the problem. An FBS measurement, although informative, would not be the priority assessment at this time, nor would a bilirubin measurement. A WBC count would indicate the possibility of an infectious source but it would not be a priority assessment in terms of the patient's presentation.

The priority assessment in evaluating a pregnant woman with severe nausea and vomiting is: a. fasting blood glucose level b. ketonuria c. bilirubin d. WBC count

C -- Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by: A. Eating six small equal meals per day. B. Reducing carbohydrates in her diet. C. Eating her meals and snacks on a fixed schedule. D. Increasing her consumption of protein.

C

What are maternal and neonatal risks associated with gestational diabetes mellitus? A. maternal premature rupture of membranes and neonatal sepsis. B. maternal hyperemesis and neonatal low birth weight. C. maternal preeclampsia and fetal Macrosomia. D. maternal placenta previa and fetal prematurity.

D -- Screening for GDM usually takes place between 24 and 28 weeks of gestation. However, the client is screened for GDM earlier if there is a history of stillbirth or birth of a malformed or macrosomic infant. A 24-year-old client would not be considered for earlier screening for GDM; maternal age older than 25 years is a risk factor for GDM. A client with a BMI of 22 is not obese and is not considered for earlier screening for GDM. If the client does not have diabetes before gestation, the client need not be screened early for GDM.

Which assessment finding does the nurse recognize as an indicator for early screening for gestational diabetes mellitus (GDM)? A. The client is 24 years old. B. The client's body mass index (BMI) is 22. C. The client does not have diabetes. D. The client had a previous stillbirth.

A -- Fetal macrosomia is a common complication associated with gestational diabetes. Hypersecretion of fetal insulin hormone as a response to maternal hyperglycemia results in an increased size of the fetus. Maternal hyperglycemia does not cause the development of uterine growths. Fetal movements may be cause for a cesarean, but they are not associated with the client's gestational diabetes. The size of the pelvic brim is not altered by maternal hyperglycemia.

Which client may need a cesarean delivery because of complications related to gestational diabetes? a. a client with a big fetus b. a client with uterine growth c. a client with reduced fetal movement d. a client with less than normal pelvic brim

C -- Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.

Which factor is known to increase the risk of gestational diabetes mellitus? a. underweight before pregnancy b. maternal age younger than 25 years c. previous birth of large infant d. previous diagnosis of type 2 diabetes mellitus

A -- The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonate's circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia.

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. hypoglycemia b. hypercalcemia c. hypobilirubinemia d. hypoinsulinemia